Most Days, I Am Fine.

After a lifetime of being on a low fat/ no fat diet, and now, after two full years of being a pretty religious vegan pescetarian (not by choice, but by intolerance necessity), I must say that I am mostly used to it. I don't crave meat anymore, even bacon, and I always tell myself that there is no need to eat “other things” since I am always full and fulfilled when I do eat what I can.

I refer to it as “not being able to color with all the crayons in the box, but still able to color, and thus still having the fun”. And I pretty much believe that. I should have probably been a vegan long before I turned 39, but I didn't have the need to until meat and animal products made me literally sick.

I am very used to my diet now, to the point that when a restaurant sneaks something in my food, I can tell immediately and I do feel sick, not happy about the inadvertent breaking of the rules.

Like I said, I don't feel restricted in any way and I don't wish “what if.” To me, those would be a waste of time and energy. I am pretty much settled in my new reality – which has been always changing over the years. Until today. And you knew this was coming, right?!

I have loved sushi, all my life. I didn't grow up eating it (we didn't have such diversity in communist, and post-communist Romania), but once I had it in The States (around 2002 or so), it was love at first bite. I have eaten it till last year in December, when my aortic valve was getting so bad that it needed surgery. I was afraid to eat any raw fish, because of all the bacteria that could be introduced into the body and damage the valve with it.

After the valve was repaired, I cannot eat it now for more than one reason: raw meat contamination is just one of them, but also, I have not found conclusive information on what the content of Vitamin K is in the seaweed wrapper, and that can throw off my INR, since I would be eating it just occasionally. Another reason for not eating it is because  I cannot eat soy (intolerant, as well), and there is a lot of soy contamination with any sushi, for sure.

So, today, our office ordered sushi for one of our office work lunches, and not only that but we had our own sushi chef on site, too. Every roll I saw leaving our kitchen was amazing – huge portions, too, and all you can eat. I thought I was going to faint. Today, I can say that it was the first time, in … ever since I can remember, that I wish my diet would be different and that I could eat sushi once again.

I ate my home-made and home brought whole grain pasta with chickpea “meat balls” and home-made tomato sauce. Yummy, too, but … not sushi. Some sacrifices we have to make, for our health.

I wish your journeys through this are easy and successful.
Much health to all!

Nine Months and Counting

Two days ago I celebrated 9 months since my surgery and things are well. I have no idea where all this time has gone! I know I was home for three full months after surgery, which (for someone who has never had medical leave before and never took more than 3 weeks of vacation at a time) seemed like an eternity. But now, I can hardly remember ever being home. I have been back to work for 6 months now, and it's all a routine again. 

I have no words to describe how incredibly grateful and humbled I am that I am here today, typing this. Although I am not the same person, physically (in so many ways) that I was a year ago, I feel well, and I am adjusting to my new reality. Living with Coumadin is not as scary as it was in the beginning. I go to the clinic every month and I take my INR myself at home, about 2-3 times in-between my clinic appointments. My INR is usually either within the range, or  higher. My range is only 1.5 to 2, so when it's 2.3 or 2.1, it doesn't concern me that much. 

My left arm has been numb since the surgery, and it's actually getting worse, for some reason. Only the pinkie and the 2 next fingers were numb, and now my whole hand and wrist are numb. No idea why. My breathing is shallow (see previous post for details), but I am learning to live with it. 

Believe it or not, I still have "pump head". I have days when words just don't come out of my mouth. I KNOW what I want to say, but I cannot say the words - and it looks like I am stuttering. I read that this could last for 5 years in some people. 

We are trying to make some plans for a cruise or some tropical vacation for later this winter, and I am a little nervous about flying again and going into different territory, outside the range of my doctors, but ... life is short. And I want to live it. And God has been so generous so far, that I feel encouraged to put this new lease HE has given me to good use.
I already started  shopping for Christmas, and we just remodeled a couple of rooms in our home. In other words: life is moving on, even after heart surgery. 9 months ago I could not have conceived I would be doing all these things in this much time. But life's a living surprise. And I am so amazed and in awe of it all! 

I asked one of my friends who has had his aortic valve replaced too about 6 years ago when will I just go through ONE day without thinking about what's going on in my chest. He said to give it at least 3 years. So, I'll try to be patient and still obsess over my heart, BUT ... I want to do things, too. So, I'll push through each day, one foot in front of the other. Worry or without. 

Another friend of mine asked me if I am going to yell at my surgeon when I see him next time (next month) for messing up my breathing and my arm, but IS SHE KIDDING??? The man practically killed me and brought me back to life in one piece! He gave me a functioning and better heart, and probably added years to my life. I have no words for the gratitude I owe him forever. I truly hope he lives forever and he gets to help many, many people. And I hope God is really good to him! I would not be here much longer if it were not for people like him, brave enough to fix hearts! 

I pray for all of the people who have to face heart surgery and are in some leg of this journey. I hope all of them have smooth rides, good teams and a lot of hope and faith! You all can do this. Medicine is amazing nowadays. Much health, strength and hope.

Eight Month Valversary

Tomorrow marks my 8 month aortic valversary. I have no idea where the time went!

As some of you already know, I have been back to work for about 5 months of those 8, and I have built up my hours to where I work about 9-10 hour days now, including the one hour commute I have every day. If you had told me this when I woke up in the ICU, I would have thought you were crazy talking. But, taking every day one at a time, with its very own challenges, and putting one foot in front of the other, I have somehow made it to 8 months. Only by His Grace, I tell you! We, humans, are small miracles.

Today was my 3 month appointment with my cardiologist and I had a followup echo, too. He did followups every 2 weeks after the surgery, then spaced them out to a month, then to three, so now, he'll do every 3 months for a bit, and then go to 6 months where I was before the surgery, so I guess that'll be back to normal.

My On-X mechanical aortic valve is still in mild regurgitation, but I'll take that over 'severe'. My surgeon said at some point that it will always leak, but as long as it stays mild or even moderate to not worry about it. Since it's a mechanical valve, the area of the valve (1.6 cm2) should not ever decrease. It was 0.4 cm2 when they called for surgery, so, again: I'll take this!

My cardiologist is much more cautious and he wants to see the regurgitation go away for good. But I'll take what I can get. My left inferior ventricle is hypokinetic, which means it does not squeeze as hard as it should – the left ventricle was the place of my heart attack, way back when I was still in the hospital, after surgery. So, that part of my heart has been slowly healing, but it's still “lazy”, for lack of a better word. I am convinced that NOTHING about our hearts is lazy. They are industrious little machines!! My ejection fraction (which was knocked down to 55% right after the heart attack) is now between 60-65%.

My blood pressure is still weird: he got a 140 over 60, and he said the gap between the two is still too large, and he's concerned about it, although he's not sure what makes it so, outside of the regurgitation in the valve. He, again, asked me if I am dizzy and I am not, so he will let the BP be for now. He told me to drink plenty of water and call him or go to the ER if I get dizzy when my BP is weird.

I have had some weirdness breathing lately. Not sure why, but I feel like my lungs “forget” to breathe and I need to push them to breathe for me. Has anyone experienced this before? And not right after surgery, but after 6-7 months after the surgery? He is puzzled, but he ordered an X-ray and a pulmonary function test to figure out what it is. It happens at rest, too, but it's more evident when I want to sprint walk, or run up a set of stairs, for instance. I feel like I am not getting enough air in my lungs and I have to make an extra effort to inflate them and release the air. It's nothing like the chest angina that I had before the surgery, though, so I am really happy about that.

Outside of all this, my left arm, which was left numb after surgery (probably from the nerves they damaged trying to pull an artery out of my chest to do the quadruple by-pass), has been feeling even worse. I am not sure if it's worse, or just different. Only 3 fingers and my left wrist were numb, but now, my whole palm, all 5 fingers, and the wrist are numb. Also, the “frozen” feeling from before has been replaced with a “wet hand feeling” now. I feel all the time, like I have cold water on my entire hand, when it's actually bone dry.

I have managed to walk up to 3 miles in a day, and do fine. But I have to stroll, not sprint. Sometimes, altitude (I do live in the Rockies) is a problem and makes me more tired, and more out of breath, even by just sitting there. Heat and altitude together have been a problem for me, this summer, but I heard from many other patients that that is something that happens to many.

I want to ask someone, anyone (doctors, patients) … at which point I stop thinking about this monkey … in my chest and just be. And just live. And just not worry about “oh, my God, is the stuff they rewired attached properly, or will it come apart any minute?! What would I do if that happens?” I want to know when I can feel 100% safe again to truly go off the grid for a whole weekend, or to jump on a plane to a foreign country and not worry that I might not get the right care (or any care at all) should I need it when I land there … I guess only time will tell, and it's going to be different for all of us.

As another heart patient on this support forum I follow was saying the other day, there are no guarantees, and we have to make a judgment call and just live life to the fullest – whatever that means to all of us. I tell you: even with good news from the doctor, I still worry. I still monitor myself closely. I still go through the motions of did I take my Coumadin? Did I eat too much salad today? Did my Indian food have too much turmeric in it? Did my cold meds or my allergy meds mess with my BP? And will I have another heart attack? Or did the bypasses take care of all the blocked arteries for a while? And what's that “while”? Another month? Week? Year? 10 years? It would be nice to know, but boy, so ungrateful and self important, too, to want to know.

My mom says “no one can add days to our lives. Only God.” To say the biggest understatement of the year: I am grateful beyond belief for the days He has given me so far. I will try, hard as it may be for this control freak, to leave the day count up to Him, and just worry about my next step. One foot in front of the other. 

Many GOOD days ahead, you all! Much health and hope!

Labor Day Adventures

We have not done many travels this year, given my recovery, my tiredness, my quirkiness about my sleeping arrangements and my paranoia that I have to be close to my doctors before I know for sure if this 'new heart' actually works on its own. 

But given that we both love to travel and photograph, we have gotten around close to home and either gone camping a couple of times, or visited some destination towns that are within driving distance. 

My doctors have not advised me against it, but I do not feel comfortable (or wise) to travel by plane right now. I am still adjusting in my new skin, really. 

For this past Labor Day, though, we drove to Moab, UT, which is only about a 3 hour drive away from us. Our previous extended trip was on July 4th, to Idaho, and I have to say I did much better this time in Moab than back in July! The heat was not as intense, either, which helped a lot. We rediscovered this desert town which we know fairly well, by visiting a new (to us) National Park (Canyonlands), a winery (I know, in Utah of all states!), and by eating at a couple of new eateries, one of them (Sunset Grill) with an amazing view of the valley. 

We did not hike very much, outside of getting out of the cars to capture some of the landscape in Canyonlands, and outside of walking the downtown from one end to another a couple of times, but I did spend lots of time in the car, which did not seem to bother me as much as before. 

Little by little, I am building more endurance, I think, to do things outside of my routine and to do them for  longer stretches of 'discomfort'. 

This is me, above above one of the overlooks in Canyonlands.  I felt very victorious climbing up on this high rock, with gusts of wind trying to pitch me in the abyss below. What beautiful country we have and how lucky I am to be able to be well enough to travel and take it all in!

Much health to all! 

Numbers Come Back to *Their* Normal

Well, the numbers I managed to score while being on Crestor+Praluent+Zetia did not stick around! (See this entry for a reminder of those numbers: http://livingwithfh.blogspot.com/2016/07/amazing-numbers-and-more.html). 

Although Crestor seems to work better for me, for cholesterol values, I have a lot more side effects while on it (pronounced fatigue and skin rash, mostly) and my liver values were up in July, also: the Alanine Aminotrasferase (or ALT) was 98 (normal between 7-52), and the Asparate Aminotrasferase (or AST) was 48 (normal between 13-39). 

I knew the culprit had to have been the Crestor, because it was the only thing that changed, so I asked my cardiologist to switch it to Lipitor, which I have been on for 16+ years with no liver side effects or otherwise. Now, the the Alanine Aminotrasferase (or ALT) is 39 and the Asparate Aminotrasferase (or AST) is 31. Both of them within normal ranges. 

The cholesterol numbers are up, again, though, with the exception of the HDL which is down (also bad for me to be this low):

Of course that every little bit helps, but I am seriously bummed that the numbers are not, still, under normal range, after 4 months now on Praluent (+Zetia+Statin). 

I am glad, though, that I am not hurting my liver more that it's necessary while trying to fix my numbers. I have found that the liver checks are helpful to tell about the condition of your liver, although some doctors (nowadays, most) don't recommend them as a requirement. I feel like all the drugs I take are going through the liver, and they are all very potent, so close watch is needed. As I understand it, liver damage is irreversible, so early detection of any liver problems is key.

The next step is to continue with the current regimen (as captured here: http://livingwithfh.blogspot.com/2016/07/my-current-drug-regimen-and-diet.html), and I guess just move the blood tests to every 3 months again, as before Praluent was in the picture. 

At this point, I am on all that the medicine market has to offer, short of changing out the PCSK9 drug to Repatha instead of Praluent, maybe?! But that option has not been given to me yet. 

Much health to everyone trying to stabilize their numbers, and I hope you're finding what works the best for you all, with minimum invasive side effects. 

About Camping and Life in the Past Six Months

I still remember every day the words of my surgeon, on the first day I saw him in ICU. Drugged up and all, I still remember him saying “Alina, this will be a loooooonnnggg recovery ...”, and he made this gesture with his hand, as if he were showing a long, wavy and bumpy river flowing in front of me. This is what drives me, most days, when I get impatient with myself and with being pulled behind.

This month, I have reached 6 months since surgery, a milestone that was only a dream when I came out of surgery. I’ve had undoubtedly less bumps than most people on here, but I had some, and I know today that my life before the surgery will never return. But that only means that I have to learn to live the new life, for which I am grateful and humbled! I’m not missing the old life, most days, but then what would be the point, right? Onward is the only direction I know.

I follow this site (www.heart-valve-surgery.com) where heart valve patients tell their stories. Reading about all their journeys and living my own is amazing to me - we’re lucky to have such great gifts: our lives, to begin with, and then this Heart Valve/ OHS community and leaning on and learning from each other. Such a blessing. The opportunity that I have had to meet my medical team, other patients, in rehab, and people online, in such forums, has been a true gift. The knowledge I have gathered during this time will save my life. I know this! This gift alone has made this journey worth it to me.

While living through the past 6 months, I’ve always thought that we all went in this thinking we’ll fix our hearts and we’ll be better. And I think some of us will do just that. But at the same time, for me, I’ve also learned that I’ll never be ‘OK’. I’ll never be “not” a heart patient. I’ll never be able to leave my house without my Coumadin, or my MedicAlert bracelet. I’ll always have just a little bit of an odd feeling in my chest. Different than before, but always a reminder. I’ll always check my heart rate and my BP almost daily, sometimes more than that. And these are all OK things. These are my new reality. I try to not label it, and just be aware of it: it’s not ‘good’, nor ‘bad’. It’s just there.

This journey gave me a new life, for sure. Not one without pain and worry, but one that is more grateful. More patient. Slower and more in-tune to my body and the world around it. I pick my battles very carefully nowadays, and I know, at the end of the day, what was important to me on that day, when I went in for OHS. For this life I am grateful and humbled, and I would not trade it for the world. Even if it will never be devoid of bumps.

We tried camping for the first time in the beginning of June - just for  one night, at a campground about 45 minutes from our house, and I thought, then, that I was going to die. My heart felt heavy and was beating erratically, my chest and back were killing me, and I felt extremely tired, and fainty.

A couple of weekends ago, we tried camping for one night again. This time, we camped “off the grid”, just on the side of a national forest road, by a stream, in the middle of pretty much nothing. Lately, I have felt better and I am s-l-o-w-l-y pushing boundaries, and try to venture out where there is no cell phone signal, although in close proximity to our house (this time we were only about 45 away, too).

This second time, I felt really good. I don’t sleep very much elevated anymore, so just a couple of pillows were enough for my sleeping arrangement. I actually could go to work and not feel like I was going to faint or die the next day, too. I did get some pains in my ribs and spine and lower back, but they were probably from being in the camper bed, which is not as comfy as my own, at home. The first time I went camping, I worked for a half day the following day, and then I came home and crashed! I could not even cook, or wanted to eat, or anything, I was drained and my blood pressure was odd. This second time, I worked full days, on Monday and Tuesday and then I came home, after 5 PM and worked in the yard for about an hour and a half each night, watered plants, planted some new ones, and cleaned up rose beds. Wednesday, I finally felt exhausted! I still worked a full day, but I came home after 5 PM and crashed! It was time - my body had had enough.

We went camping this last time at altitude, again (over 6000 ft; our house is at 4000 ft), but it didn’t seem to bother my chest at all. We went for two short hikes (less than a mile), before sunrise and after sunset, and one of them was uphill, but it was not hard to do for me. No out of breath feeling, or anything - which always surprises me.

All this time, while I was out there, and in the two days following the camping trip, my blood pressure inched towards being close to normal, too. Usually, at rest and with no exercise, the numbers are odd, 140 over 40 or some such thing, but after exercising (yard work, mostly), I saw the numbers getting closer to what is considered normal - like 113 over 48 or 113 over 52. So, although I am not ready (nor will I ever be) for a marathon, yet, I think my heart wants to start moving again.

I still live with constant reminders of my OHS, of course, and I am aware that I will never be fully free from thinking about it, or adjusting my days around it. My chest is still sore; I still call it “crunchy” as I think I have the distinct feeling that it’s made of multiple pieces, and is not one, solid bone. My incision is still sensitive - I still cheat on my seat belt, as it’s too heavy on my chest.  I still cannot lift much (like my computer bag and lunch box), and I still use a dolly for all my “work stuff” and I park in the handicap parking, at work.

My nerve damage in my left arm is still there and actually, I think it’s been getting worse. I have this frozen feeling in my pinky and ring finger which is constant; sometimes, my whole left arm feels frozen. My left leg is still numb, but different than my arm. It’s more like a log that I am pulling around. (they harvested an artery and a vein from my left chest and left leg, respectively, for the 4 CABG’s they did along with my aortic valve and ascending aorta replacements).

Heat still bothers me to no end. Even when I do nothing, even when I just sit there, the heat makes me short of breath and tired. This was the only thing that bothered me during our camping trip - it was supposed to be in the low 80’s but it was in the low 90’s instead. And even in the shade, and drinking water constantly, I felt lethargic and my chest felt heavy, as if my heart was working overtime.

I still obsess over my INR. Now, I measure it at home, and I panic when it’s something like 1.7 (my range is 1.5 to 2), because I know there is a margin of error of something up to 0.3 points. But so far, knock on wood, no bleeding nor clotting events, than Goodness! I have my cell phone alarm set permanently for 7 PM at night, to make sure I take my Coumadin the same time every day and not miss it. This will be set forever, I am sure.

I am still nervous about flying, and I think I’ll wait for up to a year before I venture out on a plane. This is just my own decision, I have not run this by any doctor. I just want to make sure I can rely fully on the new equipment I have in there. But every day, I gain a little more trust in it. I used to be nervous to be alone in the bathroom, taking  a shower, with my husband just downstairs. But now, he goes to work before me, and I am alone in the house, as I get ready for work. I drive 30 minutes to my office and I am in one piece, thank Heavens, every day. I had to get used to feeling OK about being independent again in these past months, but it’s happening.

For those of you just starting these heart journeys, all the doubt, and the questions and the fear are very normal. There is no such thing as a dumb question, so ask here, ask your medical teams and probe them till they make you feel at ease. This is about your life, and they owe you all the answers you need to know.  Learn as much as you can to set your minds at ease.

I found, for me, that knowledge has been power, and that helps me through the days when my body feels sorta shaky. Because I know some things, and because my doctors schooled me, I can trace why my body is feeling shaky some days - work, heat, non-sleep, eating or drinking the wrong things, stress all affect the way my heart feels. And as one of my PA’s said “you gotta respect the heart, man!”, so the way my heart feels is the way my whole body will feel. This journey teaches me that with every step.

Much health, confidence and strength to all of you. Smooth roads, and heart hugs to everyone. 

 

At the campsite, in the dusk, awaiting dinner. The leaves are changing already, in The Rockies. I feel like the whole year is behind us already ...  

The Specialty Pharmacy: the Long Road of Becoming a Praluent Patient

Today, I wanted to outline the process I went through before I could actually buy and benefit from a prescription of Praluent, the new PCSK9 drug approved by the FDA last year, for FH patients only.

My cardiologist prescribed Praluent (in addition to Lipitor and Zetia) since April of this year (about four months ago). There is a long and convoluted process to be approved to be on Praluent, before the insurance would pay for it. And even after that, there is another long process to actually get it delivered. But let's not jump ahead.

My cardiologist is also the head of the research center in my state for these kinds of drugs, as he is a lipidologist, as well. So, he and his staff know all the procedures they have to follow to get this approved for the patient. They have to fill out forms that ask many questions about my medical history and what other drugs have they tried and which failed and which worked by how much, and so forth.

According to their office, they filed all the right paperwork as far back as April for my insurance to approve it. My insurance called me around June saying they approved it and they would like to schedule the delivery of Praluent. However, they had approved it for the wrong strength. Between April when the doctor originally contacted them and June, he had doubled my dose, as the 75 mg/ 2 weeks did not make a huge difference in my numbers. When the insurance called me with the approval and they found out that now I need 150 mg/ 2 weeks, they said they would need to call the doctor to have them re-issue the prescription.

Fast forward to August, and through several repeated faxes from my nurse to the insurance company, asking for the approval of the right dose, I still had not heard anything from the insurance about the new dose. I had to call myself last week and get an update from them. This is something you'll need to get used to doing – staying on top of the insurance companies, as their main goal is to gather premiums and not pay. Or at least is how it feels most of the time.

Anywhoo, I called them. They did not call me. When I called, after about half an hour of waiting on hold, I got transferred to a first rep, who confirmed that my prescription was approved. I asked if they can just send it to my pharmacy, so I can pick it up (silly me!), and they literally laughed. They said, “Oh, no, ma'am, these are specialty drugs, so you will be able to only get them from our Specialty Pharmacy and you are locked into the mail delivery, every month”. After making sure they had everything they needed for the approval to be in order, they transferred me to a second rep. He was very patient and thorough and explained to me how everything works.

He will mail me (second day delivery through UPS) a dose for one month (two shots). Every month, I would have to call them, to ask for a refill. They will not automatically refill it. Because this is a “specialty drug” and still, I guess, considered experimental at this point, they don't know whether the doctor would keep me on it or not. The approval of the drug only lasts for 6 months, after which I will have to again call the doctor, who will need to fax them “my case” again, to make a point for me keeping to take this drug beyond the 6 months. Then, they'll approve it (maybe?!) for another 6 months. So, I am not only locked into mail ordering it, but also into calling them and calling my doctor and asking for the drug a lot.

The drug, he said, will come in a Styrofoam box, with ice packs in the box (Praluent needs to be stored in the fridge). They will send me an empty container for “sharps” and I will need to dispose of the injection pens in that container, and then take it, when it's full, to a specialized center. I am thinking that my doctor's office might know what to do with it. There will be an indicator, in the box, he said, that would show whether the temperature in the box dropped too much and the drugs are not good anymore (this did not happen, by the way – there was no indicator in the box).

Because I have had so many medical expenses this year, I have met my deductible and my drugs are free for the rest of the year. So, from now till the end of the year, Praluent will be free, the insurance will pay the whole amount. If it had not been for this, the shelf price, with no insurance, is $1400/ month. As you can imagine, quite high.

After I was done talking with the second rep, at the “Specialty Pharmacy”, he forwarded me (after another 15 minutes of waiting) to a Pharmacist. He went over several things with me, although I had told him I had no questions, as I have been taking samples from my cardiologist for a couple of months. He was very thorough, too. He gave me tips on how to make the injection hurt less (numbing the spot of the injection with ice cubes - which didn't work, by the way, and it made the serum build up in the “frozen” spot which gave me a huge bump on my leg). He also went over several side effects. Despite what the cardiologist had told me, he said there is a potential that Praluent could affect the liver, and that I should have to have my liver enzymes checked periodically, to ensure this does not happen. He also told me that Praluent has the tendency to make you very dehydrated. This was interesting to hear, because a month or so ago I ended up in the ER because I was dehydrated, which was unusual. I drink lots of water during the day, and even at night, but somehow, I need more water than normal, lately. I chalked it up to being a “summer thing”, but I guess Praluent can have something to do with this, too.

When I got the drugs delivered to my house, they were, as the second rep said, very safely packed in a huge Styrofoam box, with ice packs inside. There was one box that contains two pens of Praluent. There was no indicator in the box that the temperature might not have been appropriate, but the box felt very cold, so I promptly placed it in the fridge and we'll call it “good”.

After four months of forms and many-a-faxes between doctor's office and insurance, and calls between insurance and me and the other way around, I am finally, officially, a Praluent patient.

I just wanted to take some time to outline this journey, just in case you're getting ready to start yours with the “Specialty Pharmacy”. Hopefully, this will give you an idea of what to expect. If your insurance is not paying for the drugs, I am not sure how that would work and who would provide the drugs for you. I doubt that the doctor can just order them at the brick and mortar Pharmacy you use, but they might. 

 

The paraphernalia arrived: opening the enormous box from the "Specialty Pharmacy", with all the accoutrements, along with the small box of Praluent (last shot).