New jab to help patients who are at risk of going blind

RETIRED midwife Betty Short lives in fear of losing her eyesight. She has a condition called giant cell arteritis (GCA), which leads to inflammation of the blood vessels in the head and neck, reducing blood supply to the optic nerve.

If left untreated, blindness can result from this distressing condition, which also raises the risk of a stroke or an aortic aneurysm, where the main artery from the heart becomes enlarged and can rupture.

The cause of the condition, which strikes the over-50s and is up to three times more common in women, is unknown.

In Ireland, GCA affects around 20 people in every 100,000 but because awareness is so poor, it’s not known for sure how many people are living with the condition, but go undiagnosed.

Symptoms include headaches so severe you can’t bear even to brush your hair, pain in the jaw, muscle pain, blurred vision and scalp tenderness.

But because symptoms are varied, the condition is difficult to diagnose, with delays in treatment meaning that up to a quarter of patients suffer irreversible sight loss, according to Professor Bhaskar Dasgupta, a consultant rheumatologist and an expert in GCA.

The good news is there’s now a new treatment that could transform the lives of many patients.

For 70 years, the only treatment has been high-dose steroids, which reduce the inflammation.

However, long-term use of the drugs increases the risk of diabetes, osteoporosis and fracture, in addition to disturbing sleep patterns and provoking anxiety.

And not everyone responds to steroids, Professor Dasgupta points out.

‘At least 50% of patients fail to respond, and of those who do, one in every two relapses when they go on a lower dose,’ he says. ‘Some patients find they have to be on steroids for the rest of their lives.’

Betty, 74, was diagnosed with GCA in 2014 after experiencing pain on the left side of her neck and across her shoulder.

‘My GP put it down to old age,’ she explains. ‘I was 71, so I didn’t dispute it.’ A few weeks later, she developed pain in her jaw and mouth so severe that she was forced to live on liquids.

Referred to a maxillofacial unit, she was told she had strained her jaw and was given exercises.

Her mouth recovered, but one night she woke up ‘with the worst headache imaginable’.

‘My face was swollen and red and when I put my fingers up to my temples, the blood vessels felt raised. Paracetamol did not touch the pain,’ she adds.

Her GP referred her back to the local hospital, but no one could explain the headache.

Finally, six months after she developed the headache, another GP recognised it as GCA and Betty was put on a high dose of steroids. Within 48 hours, her headache had gone.

Betty continued to take steroids until last June, when her condition was deemed to be under control. But she was warned she could relapse, and, if she did, she would have to go back on them.

‘I dreaded it — they left me feeling very tired. I was unable to sleep and my face got puffy and swollen,’ she says. ‘My eyes are very important, but there’s no way I’m going back on steroids.’

Luckily, there’s now another option, Tocilizumab, a drug that targets a chemical responsible for inflammation. The results of a clinical trial, involving 251 patients and published in the New England Journal of Medicine last year, show that Tocilizumab injections — given weekly or fortnightly in combination with a rapidly-tapered dose of steroids — not only improved symptoms, but also delayed relapse.

More than half the patients on the injections showed no evidence of GCA after a year, in spite of coming off steroids altogether after six months.

The most common side-effects were occasional infections, raised cholesterol and injection-site reactions.

‘Tocilizumab helps patients achieve better control of this illness and fills what has been an unmet need,’ says Professor Dasgupta.

TOCILIZUMAB is covered by the HSE and has been available to patients in Ireland since 2009. It is administered by intravenous infusion and must be given over one hour through a drip in a patient’s vein.

Betty heard about Tocilizumab at a meeting for the charity Polymyalgia Rheumatica & Giant Cell Arteritis and had been saving €100 a month out of her pension to pay for it if she relapsed. (A year’s treatment privately could cost €11,500.)

‘Knowing there’s now an alternative to steroids gives me real peace of mind,’ she says.

DO SILVER dental fillings threaten our health by leaking mercury into our bloodstreams? Arguments about the risks of inserting the toxic metal into our teeth have raged for nearly 200 years, ever since mercury fillings first became popular in the 1830s.

The mainstream medical thinking has been that although these silver-coloured fillings exude mercury vapour into our mouths, it’s in such tiny amounts that it does not affect us.

But two perturbing developments have recently pushed the controversy back into the spotlight.

Firstly, the use of silver coloured fillings is now being reduced by Irish dentists as of July 1. The fillings will no longer be used on the teeth of children under 15 or pregnant or breastfeeding women — unless it is deemed strictly necessary for medical reasons.

Dr Kieran O’Connor, president of the Irish Dental Association (IDA), says the new regulations aim to reduce the amount of mercury in the environment.

‘Five years ago, Ireland was a signatory to the Minamata Convention and the new EU regulations governing dental amalgam stems from the phased implementation of that United Nations agreement,’ he explains.

‘The convention brought about a global agreement to reduce environmental contamination caused by mercury. It includes a ban on new mercury mines, the phase-out of existing ones and the phase down of mercury use in a number of products and processes.”

Dr Eamon Croke, who helped to produce the IDA’s patient information leaflet on the matter, says the fillings are safe, strong and long lasting.

‘Dental amalgam has been in use for over 150 years and its safety and reliability has been well researched,’ he adds.

‘In certain circumstances a dental amalgam filling may be the best option to achieve a safe and satisfactory outcome and if that is the case the dentist will explain why.

‘However, if a patient doesn’t agree they should say it to their dentist so alternative arrangements can be put in place.

‘Many people who have amalgam fillings may be wondering about their safety. Many will have had these fillings for a long time and they will be working very well.

‘Their removal is to be avoided because it usually leads to the creation of a larger cavity.’

Last week, researchers writing in the journal Radiology warned that amalgam fillings leak vastlyincreased amounts of mercury vapour when exposed to new, more powerful MRI (magnetic resonance imagery) medical scanners.

In conventional silver fillings, mercury is mixed with other metals because it makes the mixture soft enough to mould into cavities before it sets. Mercury represents about 50% of the filling by weight.

Once set, the amalgam is tougher than modern white fillings, which typically comprise powdered glass and acrylic resin.

Irish dentists are also not permitted to give medical card patients white fillings for their back teeth and say pliable amalgam fillings are much easier to fit.

They remain the most common type offered in Ireland — three quarters of us have fillings, and the majority are made of amalgam.

Numerous authoritative studies show that over time, however, the amalgam fillings emit mercury vapour. But whether the vapour may damage health lies at the heart of a medical controversy that has raged for more than 180 years.

Mercury’s toxicity has long been known. Experts say acute exposure can cause breathing difficulties, bleeding lungs, tremors and mood swings. Low-level chronic exposure may cause general feelings of malaise, weakness and irritability.

But no one has been able to establish a definitive level at which vapour from fillings may harm us. A 2015 EU safety assessment says the amount of mercury that amalgam fillings emit varies widely from person to person. Chewing, toothbrushing and tooth-grinding all accelerate each filling’s vaporisation levels, as do crunchy foods.

How much a person eats, whether they habitually breathe through their mouth, and the location of their fillings (such as the tops of their molars) can all increase their vapour intake. ‘Accordingly, exposure assessment is complicated and inherently imprecise,’ says the EU report.

Last week, however, we learnt of a significant new way in which vaporisation may be accelerated.

Scientists have discovered that powerful magnetic fields produced by ultra-high-strength MRI scanners, which are being introduced to several research hospitals, can significantly accelerate the leakage of mercury from tooth fillings within just 20 minutes.

IN A study published in the journal Radiology, Dr Selmi Yilmaz and colleagues at Akdeniz University in Turkey, measured the amount of mercury released by 20 amalgam-filled extracted teeth that were placed into 20 separate pots of artificial saliva and subjected to the high-strength MRI scanning.

These were compared with 40 teeth in saliva pots either scanned with conventional low-strength MRI or not scanned at all.

Teeth scanned with high-strength MRI leaked four times as much mercury as the other two groups, which showed no evidence of increased leeching. Whether the high level of mercury released by the new MRI machines — 0.67 parts per million — might harm patients is not known.

The team says that further research is needed to tell what reallife risk this might pose.

But concerns regarding mercuryfillings were also raised by the new regulations to restrict the use of mercury amalgam fillings in under15s and pregnant or breastfeeding women. The guidelines are in accordance with an EU ruling issued in 2016 that mercury filling use must be stopped in these ‘vulnerable groups’ unless it is unfeasible to give them white fillings for compelling reasons.

The EU wants the use of mercury amalgam stopped by 2030 to bring it