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Clinical Pharmacology > 10.2 Immunosupression > Flashcards

10.2 Immunosupression Flashcards

1
Q

What are the clinical and non clinical criteria for diagnosing rheumatoid arthritis?

A

Clinical

  • morning stiffness >1 hr
  • arthritis of >3 joints
  • arthritis of hand joints
  • symmetrical arthritis
  • rheumatoid nodules

Non clinical

  • x ray changes
  • serum rheumatoid factor/anti CCP antibodies
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2
Q

What are the treatment goals for rheumatoid arthritis?

A

Symptomatic relief

Prevent joint destruction

EARLY USE of disease modifying drugs

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3
Q

What is a mallor rash?

A

A rash across the cheeks

Often seen in lupus

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4
Q

What impacts can lupus have on the body?

A
  • seizures, headaches, psychosis in head
  • ulcers in eyes and mucous membranes
  • nausea and vomiting
  • endocarditis, pericarditis in heart
  • miscarriages and menstrual cycle irregularities
  • anaemia
  • fatigue and myalgia
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5
Q

What are the treatment goals in SLE and vasculitis?

A

Symptom relief
Reduce mortality
Prevent organ damage

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6
Q

What is systemic vasculitis?

A

Inflammation of blood vessels .

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7
Q

What is the mechanism of action of corticosteroids?

A

Prevent interleukin I-IL-1 and IL-6 production by macrophages

Inhibit all stages of T cell activation

Therefore have an immunosuppressant action

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8
Q

What are DMARDs?

A

Disease modifying anti rheumatoid drugs

They are anti inflammatories so have an immunosuppressive function

Non biological

  • sulphasalazine
  • hydroxychloroquine

Biological

  • Anti TNF agents
  • Rituximab
  • IL-6 inhibitors, JAK inhibitors
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9
Q

What is azathioprine and when is it used?

A

IBD

RA if unresponsive to other treatments

It’s is cleaved to 6 MP, an anti metabolism that decreases DNA and RNA synthesis = less inflammation

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10
Q

Why should you be careful with Azathioprine prescription?

A

Azathioprine is metabolised to 6 MP, which is then metabolised by thiopurine methyltransferase (TPMT)

TPMT levels vary in individuals

Low TPMT levels = risk of myelosupression (low bone marrow activity = low blood count)

Therefore need to do a TPMT activity test before prescribing

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11
Q

What are the ADR of Azathioprine?

A
  • bone marrow suppression (monitor FBC)
  • increased risk of malignancy esp transplant patients
  • increased infection risk
  • hepatitis
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12
Q

When are ciclosporin and tacrolimus used?

A

In transplants, atopic dermatitis and psoriasis

Not used in rheumatology due to renal toxicity

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13
Q

What drugs are CYP 450 inducers?

A

Rifampicin
Carbamazepine
Phenytoin
Omeprazole

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14
Q

What are CYP 450 inhibitors?

A 
Ciprofloxacjn 
Antifungals 
HIV antivirals
Fluoxetine 
Paroxetine
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15
Q

What are the roles of IL 1-5?

A 
IL1 = HOT (fever)
IL2 = T (cell stimulator)
IL3 = BONE (marrow stimulate) 
IL4+5 = STEAK (IgE+IgA)
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16
Q

What’s the mechanism of action of ciclosporin and tacrolimus?

A

Active against T helper cells, preventing IL2 production via calcineurin inhibition = no T cell stimulation

ciclosporin binds to cyclophilin protein
tacrolimus binds to tacrolimus protein

17
Q

when is mycophenolate mofetil used in practise?

A

primarily in transplantation

good efficacy as induction and maintanance therapy for lupud/vasculitis

NB: induction therapy is to induce remission
maintenance therapy is to maintain remission

18
Q

what is the mechanism of action of mycophenolate mofetil?

A

Is a prodrug

impairs B and T cell proliferation but spares other rapidly dividing cells

19
Q

what are the adverse effects of mycophenolate mofetil?

A

nausea
vomiting
diarrhoea

most serious = myelosuppression

20
Q

what is the action of cyclophosphamide and what are its indications?

A

a pro drug (converted by cytochrome P450 for active form)
excreted by the liver
works within 6 days

an alkylating agent
cross links DNA so that it cant replicate

many immunological effects

  • suppresses T cell activity
  • suppresses B cell activity

indications

  • lupus
  • lymphoma
21
Q

how can cyclophosphamide damage the bladder?

A

acrolein, a metabolite, is toxic to the bladder epithelium and can lead to haemorrhagic cystitis

this can be prevented through the use of aggressive hydration and/or mesna

22
Q

what are the risks of use of cyclophosphamide?

A

significant toxicity

  • infertility (under 25, negligible, 25-30, risk jumps to 12%, and 30+ = 25%)
  • increased risk of bladder cancer, lymphoma and leukaemia
  • adjust dose in renal impairment

mycophenolate mofetil is safer and as effective in lupus nephritis, HOWEVER takes 6 weeks to start to work unlike the 10 days of cyclophosphamide

23
Q

what are the indications and roles of methotrexate?

A

indications

  • RA
  • Malignancy
  • psoriasis
  • crohns disease

unlicensed roles

  • inflammatory myopathies
  • vasculitis
  • steroid sparing agent in asthma
24
Q

what is the mechanism of action of methotrexate?

A

IN MALIGNANT DISEASES

it competitively and reversibly inhibits dihydrofolate reductase (high affinity for it, higher than folate)

dihydrofolate reductase catalyses a key stage in purine and thymidine synthesis

methotrexate, therefore, inhibits DNA, RNA and protein synthesis in the S phase of the cell cycle

MECHANISM IN NON MECHANISM DISEASES E.G RA, PSORIASIS IS NOT CLEAR

25
Q

what are the pharmacokinetics of methotrexate?

A
  • oral biovaliability is lower than IM
  • administered POM IM or S/C

if nausea occours with PO, swap to S/C

WEEKLY, not daily doses due to long half life

50% protein bound. NSAIDs displace however.
renally excreted

26
Q

what are the adverse effects of methotrexate?

A
  • mucositis
  • marrow supression
  • hepatitis and cirrhosis
  • pneumonitis
  • infection risk
  • HIGHLY teratogenic, abortifacient
27
Q

what are the indications of sulfasalazine?

A

for

  • RA
  • relieve pain and stiffness (an anti inflammatory - 5-aminosalicyclic acid component )
  • fight infection (sulfapyridine molecule component)

safe in pregnancy though and very few DDI!!!

28
Q

what are the immunological effects of sulfasalazine?

A

T cell

  • inhibition of proliferation
  • possible T cell apoptosis
  • inhibition of IL-2 production

Neutrophil

  • reduced chemotaxis
  • reduced degranulation
29
Q

what are the ADR of sulfasalazine?

A
  • myelosuppression
  • hepatitis
  • Rash
  • nausea
  • abdo pain/vomitting
30
Q

what are the effects of blocking TNFa?

A
  • reduced inflammation
  • reduced angiogenesis
  • reduced joint distruction

Clinical Pharmacology (27 decks)

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