More Than a Patient

The man who saved my life, twice. Dr. Ahn.

We often talk about great doctors, those men and women who treat us with dignity and respect. They listen to us, help us, work with us, and care. Those doctors are special, and when they retire or move away, it is difficult to replace them.

When I received the letter informing me that Dr. Ahn was retiring effective February 2018, I was sad but certain that another physician at the University of Miami would take good care of me. Would they be Dr. Ahn? No, no one could ever be him. I certainly never imagined I would be treated horribly and struggling to get Rituxan for a second time.

Which brings me to writing this blog. Today I had my one month post-Rituxan checkup, and my platelets are holding strong at 236,000. Besides feeling relieved and victorious, I also became very emotional. It dawned on me that none of this would have been possible without Dr. Ahn. Had I been diagnosed after he retired, who knows where I would be (or if I would even be alive). He gave me the tools to fight this disease, fight for myself, and fight for a better world for patients like me.

I thought back to the scared 27 year old in his exam room, unsure of what the future holds. I felt like my life was spiraling out of control. I questioned if life was worth living, if my existence was a burden on everyone around me. I was beaten down and demoralized by my diagnosis, yet this man saw something in me that I could not see in myself. He saw the real me, the fire and determination that while stifled at the time, was under the surface. It just needed to be cultivated within my “new normal”.

I didn’t realize it, but Dr. Ahn took me under his wing and started teaching me about my disease, how the human body operates, and what he had learned over decades of studying platelet disorders. He sent me home to research treatments not because he didn’t want to treat me, but he wanted me to find the answer myself and come back to him. He was building up my confidence and repairing my broken spirit. I was being taught to think like a researcher, to put myself in Dr. Ahn’s shoes. Little did I know, five years later I would be using what he taught me to save my life again. Only this time, without him there to coach me.

If I had to describe what fighting ITP is like, I would liken it to walking a tightrope. Under Dr. Ahn, I had a safety net. My fear of falling was minimal because he was there to protect me. This time, it was like showing up and discovering you have a rope and a stick. No safety net and no one to help if you fall. Despite this, I stuck to what I knew- everything Dr. Ahn taught me.

Here I am in remission, again.

While Dr. Ahn treated my ITP, he also assisted me in rebuilding my life with a rare disease. I often joke that he created a monster, but truly I would not be where I am today if not for him. His lessons and mentorship helped me fight ITP in his absence. He gave me the confidence to walk the tightrope without a safety net.

I’m forever grateful that he believed in me, and saw my potential at the lowest point in my life. Every day is a gift, thanks to Dr. Ahn.

The Doctor Didn’t Listen

When I found out my platelets were below normal this year, I went through a variety of emotions, but absent was fear. I was in remission for four years and three months, surely I could do it again. After all, I was in the same hospital system seeing a colleague of my favorite doctor, I thought for sure it would be smooth sailing.

I was wrong.

I had to push for weekly CBCs, not being taken seriously about how quickly my platelets could crash. Two weeks later, I dropped from 129,000 to 53,000. I was put on Prednisone, the drug that destroyed my body and left lasting damage. The doctor assured me it was only a temporary treatment. I thought once ITP showed him what it was capable of, he would take what I say seriously.

Again, I was wrong.

My platelets started to rise, and stayed stable on high doses, but that drug was killing me. I kept asking my doctor about Rituxan, my life saver. The one drug that Dr. Ahn and I knew would put ITP into remission. It dangled in front of me like a carrot. He again refused to prescribe me Rituxan, he was perfectly fine leaving me on the drug that was destroying my body. The doctor kept saying, “Rituxan is not a benign treatment.”

I was in self-preservation mode at this point, getting worse as the weeks went by. I found my new physician, who knew Dr. Ahn and his research. I opened up to him about my desire to use Rituxan and he didn’t string me along. Instead, we created a plan based on how I wanted to fight ITP.

Rituxan worked, again.

I spent four weeks watching as the infusions started fighting back. I also was slowly feeling like myself, regaining my identity beyond just being “sick”.

After all of this, my emotions are still a bit raw. However, I am reminded that Dr. Ahn gave me the tools to continue to fight this disease well after he retired. It wasn’t just preparation for a single victory against ITP, but a lifetime of fighting back.

So here I am, in remission.

The doctor didn’t listen, so I found one who did.

Remission Accomplished

Left: Bloodwork two weeks after IVIg. Right: Bloodwork one week after my final Rituxan infusion.

My second attempt at repurposing Rituxan was a success. The last two weeks were busy and I was tired, so I decided not to blog.

It was incredible to see my platelets return to normal half way through the infusions. I continued with the IV steroids as part of my pre-medication routine, so I did not have any reactions. However, I had to ask for it every time so I will be requesting that this becomes a standard part of infusion prep when we start a trial. While they generally just give Benadryl and Tylenol to cancer patients using Rituxan because they need to gauge their reaction, this is unnecessary for ITP.

On the left is my bloodwork taken before my third infusion, on the right was my CBC before my final infusion. Huge difference in one week!

Overall, I am relieved that I am back in remission again. However, this was quite the physical and emotional rollercoaster. I am still tired, and likely will be for the next few weeks. I am trying to take a short nap every day to keep my energy up. I have noticed that the brain fog is completely gone, and I am very “clear headed” now. The purpura is gone, but I do have some darker spots where they once were. I am hoping they will go away in a few more weeks. My taste buds are still a little off, but not nearly as bad as before.

I’m still pretty burnt out emotionally, this was a hard fight and it took a lot out of me having to constantly advocate for every little thing. I certainly don’t want to go through this again in a few years when ITP comes back, so I am pushing to get Rituxan on label.

I’ll see the doctor again next month, and it will be interesting to see what my platelets are at. From there, we will decide how often I see him. I am looking forward to a break! I will be seeing a new Rheumatologist to address my Fibromyalgia and Sjögren’s Syndrome. However, I have noticed less joint pain since I finished my infusions. Perhaps some of that was B-cell related as well.

Infusion #2- It’s working!

The photo above shows my last two CBCs. I was at 94,000 platelets when I had my first Rituxan infusion on 7/1, and before my second infusion this past Monday (7/8), I went up to 100,000! I was killing off around 12,000 platelets a day before treatment, so this was extremely impressive.

I am feeling pretty good despite the mild headaches, constipation, fatigue, and lack of appetite. Those things really don’t bother me when I know my B-cells are being suppressed!

My next infusion is Monday, and I’ll have another CBC before treatment. I am curious to see where my platelets will be at the half-way mark. I’ve noticed my purpura fading, I haven’t developed any new bruises and I have no brain fog. So far, a night and day difference.

Some other good news: my nurse Jen was able to tap my wrist for the infusion, which saved me from having to hold my arm straight for a few hours. I also was administered 100mg of IV steroids in addition to Benadryl and Tylenol as pre-meds. I infused pretty quickly, from 10 am to 1:15pm, with no reaction. The only thing I don’t like about my wrist is the burning in my arm after Benadryl. It hurts for about 15 minutes and then subsides. I also have to be careful that I don’t let anything touch the area for 24 hours after, because it is tender. I usually wear my Apple Watch on my left wrist, but have to keep it off while the area heals.

That’s the update for now, I am happy with how things are progressing and ready for infusion three. #PlateletsUp

Infusion One in the Books

This is my “I’m finally getting Rituxan!” smile.

I’m home from my first Rituxan infusion, only three left to go!

While I’m smiling, I need to be brutally honest. Today was hard, the smile is put on. I’m tired, stressed, and I had another massive emotional rollercoaster caused by our broken healthcare system. I almost didn’t have my infusion today.

It was my first time taking an infusion at the elbow. While I had to focus on keeping my arm straight, it hurt a lot less and didn’t burn!

First, upon my arrival to the infusion center my authorization was not in the system. Instead of calling upstairs to get the information, they made me go upstairs to find the employee responsible. Why it couldn’t have been handled by a phone call I’ll never know. Just another part of the process where the systems and staff don’t seem to have an open line of communication. Insurance issues are handled in an entirely separate department and no one knows how to navigate it outside of a few people. Thankfully, the problem was fixed with a phone call down to the infusion center from the authorization staff.

When signing all the paperwork to do Rituxan last Tuesday, I had to take a pregnancy test to process the orders. It took my doctor a good ten minutes of navigating the EHR system to determine which of the tests was needed for Rituxan. At no point was a Hepatitis B panel shown, but apparently I needed that too. Unfortunately when I went to infuse today, my treatment was almost cancelled because I didn’t have the panel done. It wasn’t discovered until the Pharmacy was prepping my infusion. My amazing nurse got my doctor on the phone (he’s out on vacation) to override the testing requirement so we could get the prescription processing. She ended up drawing blood and everything came back fine.

At the time this all went down, I finally broke down and cried. This disease has been a constant source of unrelenting stress since March. I honestly never anticipated having this much trouble when ITP came back. Pair that with not sleeping and feeling generally miserable because of crashing platelets, I couldn’t hold in my frustration any longer.

While I tend to handle my disease with sarcasm, humor, and witty banter, I am still human with raw emotions. The system is not designed for rare disease patients, especially ones who are using off label therapies. We are forced to micromanage care, and anytime you look away, you risk someone else dropping the ball. Most of the time, those people are not the ones directly caring for you (like doctors or nurses), so it makes advocating for yourself much more difficult.

I absolutely hate having to be assertive, direct, and at times downright demanding to get what I need to battle ITP. I want to find creative solutions to the problems all of us rare disease patients face. Every time I’ve shared these bumps in the road, patients tell me their horror stories. I know we are not alone, but it seems like the system temporarily corrects itself for one of us, then goes right back to operating under broken processes. At the end of the day, this helps no one, because the cycle continues.

I hope that after all my infusions are finished and I am back in remission, I can work with payers, hospital systems, EHR companies, legislators and rare disease groups to fix a lot of these issues. There’s no sense in dismissing them once my treatments are over, because I will eventually be back in the system when I come out of remission again. I also want to turn negatives into positives. I want my challenges, problems, and pain points to help inspire change.

Now on to some interesting things about today’s infusion:

I had a reaction an hour in, complete with itchy eyes, throat and ears. I became flushed while my nose got stuffy. They had to stop the infusion and administer more Benadryl plus IV steroids. I had pre-meds of Benadryl and Tylenol, but no steroids. That’s likely what caused my allergic reaction (it was similar to what I experience with cats). For the next three infusions, I am going to ask for the steroids as pre-meds too.

My platelets went from 169,000 to 94,000 in 6 days. I am destroying them rapidly, so I am anxious to see how quickly Rituxan will work.

Food already tastes a little bland, but I’m hoping that will help me lose the 10lbs I gained from steroids!

Now that infusion one is finished, I am anxiously awaiting next Monday. Keeping my fingers crossed that the rest of the process is smooth from here on out. I appreciate the compassion shown by my nurse today. She went above and beyond to advocate for me when I felt defeated. She made it happen, and for that I am eternally grateful.

#PlateletsUp

My N-of-1 Odyssey

On Monday 7/1, I’ll be repurposing Rituxan for Immune Thrombocytopenia for a second time. The goal is to put me back into remission for an extended period of time. When I used Rituxan at the end of 2014, I had a remission period over four years. I’d like to think we will be able to achieve similar results this time around.

Rituxan is a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20. In plain English, it targets B-cells by going after CD20 which is expressed on the surface. Ultimately, after multiple blood tests and positive results from immunosuppression by steroids, we were able to figure out my B-cells were responsible for destroying my platelets. By shutting them down using Rituxan, I am able to maintain a normal platelet count.

The first test I received is Anti-Nuclear Antibody (ANA) which came back positive and indicates autoimmune activity. We also tested for Lupus, Rheumatoid Arthritis, and Sjögren’s Syndrome among others. I ended up also testing positive for SS-B antibodies, further confirming autoimmune activity. Another great marker: I respond very well to immune suppression with Prednisone. All of these factors collectively helped my doctor come to the conclusion that I had chronic Immune Thrombocytopenia and I was destroying platelets via my B-cells. I never had a bone marrow biopsy because when I am on high doses of Prednisone, my platelet count returns to normal. There is nothing to indicate that I have any issues with platelet production in my bone marrow.

Because of this, N-Plate and Promacta would not be the right treatment for me. I could stimulate platelet production, but my B-cells would destroy those platelets as well. Ultimately, the idea is to stop the process of platelet destruction. That’s how I came to the decision to use Rituxan in 2014, and why I advocated so hard to use it again this time.

So now I begin the process of making myself an N-of-1 example of how Rituxan can help ITP patients with B-cell led destruction of platelets. We will collect a CBC before each of the four infusions to track progress. I am currently on no medication for my platelets after I finished my Dexamethasone pulse last Monday (one week before my first infusion).

Besides chasing remission for a second time, I had an inordinate amount of trouble getting insurance to approve this treatment. We must see to it that Rituxan become an on-label therapy for Immune Thrombocytopenia, especially since patients with B-cell led destruction of their platelets do not have an FDA-approved treatment.

Acknowledging the clinical diversity of ITP is a must, especially with multiple drugs on the market and more in development. There is no one size fits all treatment for ITP, and what works for me may not work for another patient. Gathering treatment data and comparing it with ANA tests will be a great way to dissect some potential remission patterns in patients.

Chasing Remission a Second Time

6/7/2019 my first IVIg infusion

It took 14 days for my platelets to plummet back to a level low enough where I was beginning to bleed again. I had my first IVIg infusion at the beginning of the month, starting off at 20,000 platelets. My vein blew during the CBC beforehand. My insurance played games with approval, causing a four hour delay that ultimately rushed my treatment. 48 hours later, I was suffering with the classic symptoms of aseptic meningitis (don’t worry, an adverse event report has already been filed and I am okay).

My platelets reached 98,000 three days after the infusion, then 78,000 and 14 days later, back down to 21,000. Given all I went through, this was a disappointment. However, notably absent is my Sjögren’s related pain, so I won’t say this is a total loss. I declined doing one more infusion because I don’t believe a 14 day window is worth it. Ironically, Dr. Ahn predicted back in 2014 that an IVIg infusion would last no more than two weeks, again showing how absolutely brilliant he is!

There are a few questions surrounding IVIg and how it will impact ITP patients with B-cell led destruction of platelets. I wonder if the prevalence of other autoimmune activity shortened the effectiveness of the infusion, or perhaps if I did two back to back, would it have lasted longer? I don’t feel the need to put myself in a lab rat position for this, simply because the scientific evidence is not compelling enough for a second look right now. I have my eyes set on the long term goal.

I ended up doing a Dex pulse for four days, and today is my last dose of 10 pills. This is not as bad as Prednisone in that it is quick, but it still comes with major side effects. Heartburn, insomnia, irritability, sweating, etc. Pretty much the same things I experienced before. Tomorrow morning I will have my platelets checked again, and I am curious to see how much they popped up.

Which brings me to the big news: we are trying Rituxan again. I have been waiting to hear those words since March, and I have dealt with a lot of miserable experiences to get here. This time is much different, I know what to expect, but the stakes are higher. I want to see Rituxan become an on-label treatment for patients with Chronic Immune Thrombocytopenia that have B-cell led destruction of platelets. That means it is not for people with T-cell issues, platelet production issues (who respond well to N-Plate and/or Promacta), and those on Tavalisse.

I launched the ITP Patient Driven Research Initiative last month to tackle this issue, and ultimately work toward better targeted therapies for patients with my rare disease. The research and drug development currently underway is a start, but we can do better. A solid data platform led by patients inputting their results based on a variety of treatments over extended periods of time will help us develop data sets needed for better treatment protocols. From there, we can acknowledge the clinical diversity of ITP and get pharmaceutical companies on board to run better clinical trials.

That’s the update for now. I have an early day at the hospital tomorrow with bloodwork and planning. I’m hoping to start infusing ASAP, especially since I have been through the platelet olympics these past few months.

New Therapy Jitters: IVIg

Thursday’s doctor visit was a rollercoaster. I ended up at 31,000 platelets and needing treatment, so he suggested we try IVIge. Cue major nerves, I have spent the last five years reading about the brutal side effects other ITP patients experienced, so I am worried about how I will feel after the infusion.

I’m curious to see how long my platelets will remain at a normal level after treatment. At the height of my platelet destruction in 2014, Dr. Ahn believed it wouldn’t hold for more than 10-14 days. However, this time around I caught it early, so the outcome may be entirely different. I am happy it is only one infusion, instead of four, and will hopefully have me back on my feet after the weekend.

So how am I preparing for it? First- I asked fellow patients. The hospital told me to hydrate, but I wanted to hear from people who have been in my position. Thankfully, everyone told me to load up on electrolytes, so I bought a ton of Powerade (Seminoles don’t drink that gator-garbage), Smart Water and Coconut water. I’m also planning to eat soft foods the day before, during, and a few days after the infusion in case I have vomiting. Because my teeth were weakened by past prednisone usage, I want to minimize any potential damage that can be caused by throwing up. Infusion clinics really should be giving out this advice when you schedule your appointment, but that is a fight for another day. I want no surprises, so I’m glad I asked because just chugging water the day before was not going to cut it.

The most difficult part about this infusion is the unknown. I did not experience this level of apprehension when I used Rituxan, but I was confident it was going to work. This is a sort of a shot in the dark, I expect for the treatment to fail after a few weeks and my platelet count to drop. However, we need the data and we need to see how I tolerate it. So I’ll play along, for science.

To everyone who offered advice, thank you.

Pre-Visit Nerves

It’s no secret this go-around with ITP has been stressful. I thought by now I would be close to finishing another round of Rituxan, but since Dr. Ahn retired, no such luck.

Tomorrow I see my new hematologist again, he’s taking blood and after the results come back (within 10-15 minutes), a plan will be crafted. Why the nerves? I’m afraid of once again being told I need to “wait” for treatment.

Because my platelets can drop to zero pretty quickly, there is no sense in waiting around for it to happen. Unfortunately, ITP treatment varies by doctor and some are willing to wait until I get very low. I know my body well enough to know that will come quick, so acting now is best. After all, we wouldn’t wait until cancer reached a more advanced stage before issuing chemo. ITP should be treated no differently.

This is a short blog tonight, I need to try and get some rest, but I wanted to document my nervousness because I know there are other patients out there like me. I guess this is “normal”, but it shouldn’t be. I should be able to access the treatment that saved my life once before. I’m chasing that “new normal” I started blogging about almost five years ago. I want to go back to being myself, not living week to week between lab appointments.