29. Autoimmune Conditions Flashcards
Susan is a 78 year-old female patient with Sjogren’s syndrome. Susan has considerable difficulty with dry eyes, and dry mouth. She asks the pharmacist for advice on helping her manage the dry mouth. Which of of the following statements concerning dry mouth are correct? (Select ALL that apply.)
A. Biotene Gel and Mouth Kote are saliva substitutes that may be helpful.
B. If using sugar free-gum, sorbitol can help prevent cavities but xylitol might cause diarrhea.
C. Pilocarpine in the oral form (Salagen) or cevimeline (Exovac) will increase salivation; they are, however, pricey and can cause urination and sweating.
D. Try to avoid anticholinergic agents in anyone who has glaucoma that is not well-controlled; they may worsen the condition.
E. A major complication of dry mouth is tooth decay.
A, C, D, E. If using sugar free-gum, sorbitol can cause diarrhea and possible cramping, particular in IBS patients or anyone with difficulty taking sorbitol. Xylitol may be useful in chewing gum for cavity prevention. For dry mouth always use sugar-free candy or gum. A major complication of dry mouth is tooth decay (dental caries, or cavities).
Sjogren’s Syndrome
Autoimmune disease most often characterized by severe dry eyes and dry mouth.
Dry eyes: use artificial teardrops (1st line) available OTC. Cyclosporine eye drops (Restasis) can be used in patients who do not get satisfactory relief from other methods. Restasis is an emulsion applied twice daily (remove contact lenses before use) and separate from artificial tears by 15 minutes.
Dry mouth: Cholinergic drugs would produce saliva. Pilocarpine (Salagen) dosed 4x/day. Cevimeline (Evoxac) dosed TID. CI for both drugs: uncontrolled asthma, narrow-angle glaucoma
Etanercept carries the following health risks, which must be conveyed to the patient: (Select ALL that apply.)
A. Teratogenicity
B. Liver damage
C. Exacerbation of heart failure
D. Risk of infection
E. Reactivation of latent TB
B, C, D, E. For liver monitoring, instruct the patient to call the doctor right away if they have any of these symptoms: feeling very tired, skin or eyes look yellow, poor appetite or vomiting, or pain on the right side of the stomach. Instruct patients that this medicine may worsen congestive heart failure (CHF). They must notify the doctor right away if they experience a sudden weight gain or shortness of breath.
etanercept (Enbrel) – Anti-TNF, 50mg SC weekly
Warnings: serious infections and malignancies (remember LIST)
L – lymphomas, I – infections , S – skin cancer, T – tuberculosis
Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)
No live vaccines
Antibody induction: may develop antibodies against these agents which reduces efficacy
Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)
Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs
Charles is a 40 year-old patient who has had “stomach issues” for many years, including pain after eating. He has been self-treating for many years by avoiding foods he knows will cause bad symptoms, including bread. Recently, he saw a gastroenterologist who diagnosed celiac disease and recommended avoiding all gluten intake, including in even very small amounts. Charles is a regular at your pharmacy. He has come in to pick up his medications and asks to speak to the pharmacist. He tells the pharmacist he cannot take any pills that contain gluten. What key words will the pharmacist search for in the package insert in order to check if gluten is present in the excipients?
A. Starch, or wheat
B. Starch, or corn
C. Starch, or potato
D. Starch, or rice
E. Starch, or flax seed
A. The pharmacist is checking for wheat. If the word starch is used, it could be wheat. If starch is listed without specifying the type, the manufacturer should be contacted. They may or may not verify the ingredients used as excipients because they may not wish to take responsibility for bulk products they purchase. In the celiac chapter of the RxPrep text resources are listed which could be used to attempt to verify content.
Celiac Disease
Gluten found in barley, wheat, and rye. Triggers an immune response in the small intestine and chronic inflammation leads to damage of the small intestine’s lining and prevents absorption of some nutrients.
Drugs are gluten-free, excipients may not be.
Improper administration of Restasis can lead to infections, some of which have caused sight loss. Which of the following statement/s concerning Restasis is correct? (Select ALL that apply.)
A. The correct dose is one drop twice daily, approximately twelve hours apart.
B. One vial should be used each time, and immediately discarded after each use. Do not keep any leftover medication.
C. It could take 3 to 6 months after beginning therapy to notice an increase in tear production.
D. The most common side effect is a temporary burning sensation.
E. The active ingredient is pilocarpine.
A, B, C, D. The most common side effect is a temporary burning sensation, although many patients find the drop soothing since the eye is very dry and it is a liquid. Other side effects include eye redness, discharge, watery eyes, eye pain and/or a foreign body sensation. Most patients notice an increase in tear production in about a month (if it works) but some take much longer to see a benefit.
Dry eyes: use artificial teardrops (1st line) available OTC. Cyclosporine eye drops (Restasis) can be used in patients who do not get satisfactory relief from other methods. Restasis is an emulsion applied twice daily (remove contact lenses before use) and separate from artificial tears by 15 minutes.
A patient using methotrexate for rheumatoid arthritis should receive the following instructions from the pharmacist concerning the dosing schedule:
A. This medication is taken weekly.
B. This medication is taken daily.
C. This medication is taken monthly.
D. This medication is used only when you have an acute flare.
E. If you experience an acute flare, double the daily dose.
A.
In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.
methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD
Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose
SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, alopecia (using auto-injector can bypass GI problems)
CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)
Folic acid supplementation on the day after MTX
CY is a rheumatoid arthritis patient that states she had a hypersensitivity reaction to etanercept. What drug class does etanercept belong?
A. Anti-CD 20
B. Folate antagonist
C. Interferon inhibitor
D. Interleukin inhibitor
E. Tumor necrosis factor inhibitor
E. Etanercept is a TNF inhibitor.
Biologic DMARDs
2 categories: TNF and non-TNF
Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line
Non-TNF inhibitors: 2nd line
Warnings: serious infections and malignancies (remember LIST)
L – lymphomas, I – infections , S – skin cancer, T – tuberculosis
Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)
No live vaccines
Antibody induction: may develop antibodies against these agents which reduces efficacy
Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)
Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs
Anti-TNF
etanercept (Enbrel) – Anti-TNF, 50mg SC weekly
adalimumab (Humira): 40mg SC every other week, or weekly when without MTX
infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions
certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks
golimumab (Simponi): 50mg SC monthly, IV requires filter
HR is a 44 y/o female who comes to the clinic with complaints of a red rash over the bridge of her nose. The rash is not painful and it is not pruritic. She has been taking the following medications for the past 2 years: omeprazole, aspirin, hydrochlorothiazide, hydralazine, atorvastatin, and sertraline. Which of HR’s medications is most likely causing her rash?
A. Aspirin
B. Hydrochlorothiazide
C. Hydralazine
D. Atorvastatin
E. Sertraline
C. Hydralazine can cause drug-induced systemic lupus erythematosus (SLE).
Systemic Lupus Erythematosus (SLE)
Female, 15-45 years, African American
Butterfly rash (not painful), photosensitivity, joint pain, fatigue, weight loss
Lupus nephritis, hematologic and neurologic problems
Drug-induced Lupus Erythematosus (DILE): procainamide is most common drug that causes this, hydralazine (alone and in BiDil)
What is the mechanism of action of Raynaud’s Phenomenon?
A. Inflammation
B. Vasospasm
C. Hypotension
D. Angina
E. Migraines
B. Raynaud’s is triggered by exposure to cold and/or emotional stress, which causes vasospasm in the extremities.
Raynaud’s
Cold or stress can trigger vasospasm of small blood vessels. Skin turns white then to blue fingers and toes. When warmed, painful swelling can occur in hands and feet.
Drug of choice are calcium channel blockers. Nifedipine is commonly used for prevention.
Celiac disease (celiac sprue) is an immune response to gluten. Which of the following contain gluten? (Select ALL that apply.)
A. Wheat
B. Barley
C. Oats
D. Rye
E. Rice
A, B, D.
Celiac Disease
Gluten found in barley, wheat, and rye. Triggers an immune response in the small intestine and chronic inflammation leads to damage of the small intestine’s lining and prevents absorption of some nutrients.
Drugs are gluten-free, excipients may not be.
Which of the following is an oral agent that is FDA-approved for the treatment of MS?
A. Alemtuzumab (Campath)
B. Fingolimod (Gilenya)
C. Cyclophosphamide (Cytoxan)
D. Methotrexate (Rheumatrex)
E. Rituximab
B. All of the above agents are used for MS, but only Fingolimod (Gilenya) has the approval.
Oral agents for MS
teriflunomide (Aubagio): active metabolite of leflunomide: pregnacy (X), boxed warning of hepatoxicity (monitor)
fingolimod (Gilenya): sensitive to moisture, CI in recent cardiovascular events (within 6 months), first dose must be given in doctor’s office because profound decrease in heart rate, monitor BP HR and ECG. Remember that this drug has lots of heart problems and the “len” in Gilenya causes macular edema (eye exam)
dimethyl fumarate (Tecfidera): GI events (NVD, abdominal pain, dyspepsia) can be mitigate by titrating dose and taking it after a large meal (large breakfast and dinner since dosed BID). SE: flushing (40%) can give aspirin to reduce flushing.
dalfampridine (Ampyra): does not work for everyone, it primarily improves walking. CI in seizures or hx of seizures
natanlizumab (Tysabril): given IV every 4 weeks, know PML boxed warning (progressive multifocal leukoencephalopathy). Stable in NS only and requires protection from light
alemtuzumab (Lemtrada, Campath): first course is 12mg IV (over 4 hours) x 5 days, then second course is 12mg IV x 3 days 12 month after first course. Indicated only for refractory cases to MS drugs (tried and failed 2 or more drugs). Premedicate to reduce infusion-related reactions.
The pharmacist will counsel a patient beginning etanercept therapy. Choose the correct statement:
A. Etanercept is injected subcutaneously (SC) under the skin of the thigh, abdomen, or upper arm.
B. Store in the freezer.
C. The injection is given daily.
D. Shake the vial prior to injecting.
E. Etanercept must be administered by a healthcare professional.
A. The correct instructions are to allow the medicine to warm to room temperature before injecting (takes 15-30 minutes). Etanercept and the other biologic injectables used for RA are refrigerated (etanercept can be left at room temperature for up to 14 days). Do not shake the vial to warm it, but do instruct the patient to allow it to sit for 15-30 minutes prior to injecting. It is painful (more swelling) if a cold substance is injected. They are self-injected (SC).
Biologic DMARDs
2 categories: TNF and non-TNF
Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line
Non-TNF inhibitors: 2nd line
Warnings: serious infections and malignancies (remember LIST)
L – lymphomas, I – infections , S – skin cancer, T – tuberculosis
Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)
No live vaccines
Antibody induction: may develop antibodies against these agents which reduces efficacy
Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)
Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs
Anti-TNF
etanercept (Enbrel) – Anti-TNF, 50mg SC weekly
adalimumab (Humira): 40mg SC every other week, or weekly when without MTX
infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions
certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks
golimumab (Simponi): 50mg SC monthly, IV requires filter
Which of the following drugs is not a interferon beta formulation?
A. Rebif
B. Avonex
C. Betaseron
D. Copaxone
E. Extavia
D. Glatiramer acetate (Copaxone) is not an interferon beta formulation, but it is (along with the others listed–which are beta interferons) a commonly used SC injectable used in the treatment of MS.
glatiramer (Copaxone): 20mg SC daily or 40mg SC 3x/week, can be stored at room temp (up to 1 month), pregnancy (B), can be injected in abdomen, thigh, back of upper arm, and buttocks
Interferon beta-1a and 1b: antiviral and antiproliferative effects
Avonex (beta-1a): IM weekly, store in refrigerator
Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator
Betaseron, Extravia (beta-1b): SC every other day, store at room temperature
Plegridy (beta-1a): SC every 14 days
Start all of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble
Botox is used for localized pain and for muscle spasms in patients with MS. Which of the following statements concerning Botox is correct?
A. Botox needs to be used within 4 hours after reconstitution.
B. Botox has one indication, for upper limb spasticity.
C. Botox does not contain either human or animal product.
D. Botox makes the facial skin wrinkled, and should be used with caution in people who care about their looks.
E. Botox is onabotulinimtoxinA and is injected into muscles.
E. Botox is a popular drug and is used by dermatologists for “frown line” wrinkles in the forehead. It is used for a variety of medical conditions, including blepharospasm (eyelid twitching), cervical dystonia, chronic migraine, overactive bladder, strabismus (crossed-eyes) and muscle spasticity in conditions such as MS. It contains albumin, from human blood. .
A patient removes her MS injection device from the refrigerator. She lets the medication reach room temperature. This patient also uses insulin and she often shakes out the air bubbles prior to injecting her insulin dose. However, she does not dislodge any air bubble that she may see in her MS injection. Why is she careful not to expel any small air bubble from the MS medication?
A. It could cause the injection device to rupture if she taps on the device.
B. It would cause her to lose some of the dose.
C. The air mixes with the medication to form a suspension.
D. The air reduces the pain from the injection.
E. It is not actually air, but rather an optical illusion.
B. Do not dislodge the air bubble from these medications.
glatiramer (Copaxone): 20mg SC daily or 40mg SC 3x/week, can be stored at room temp (up to 1 month), pregnancy (B), can be injected in abdomen, thigh, back of upper arm, and buttocks
Interferon beta-1a and 1b: antiviral and antiproliferative effects
Avonex (beta-1a): IM weekly, store in refrigerator
Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator
Betaseron, Extravia (beta-1b): SC every other day, store at room temperature
Plegridy (beta-1a): SC every 14 days
Start all of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble (may lose some of the dose)
Choose the correct statement concerning shaking injectable interferons used in MS:
A. Do not shake.
B. Shake vigorously for 10 seconds.
C. Shake vigorously for 30 seconds.
D. Shake vigorously for 1 minute.
E. Let stand to room temperature, and then shake for 15 seconds.
A. Some SC injectables are shaken, including some of the vaccines, but not these drugs. The protein components could be damaged.
Interferon beta-1a and 1b: antiviral and antiproliferative effects
Avonex (beta-1a): IM weekly, store in refrigerator
Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator
Betaseron, Extravia (beta-1b): SC every other day, store at room temperature
Plegridy (beta-1a): SC every 14 days
Start all of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble (may lose some of the dose), do not shake
A patient presents with symptoms characteristic of rheumatoid arthritis. The diagnosis requires lab and other tests, which will require time to evaluate. Since rheumatoid arthritis damages the joints and organs, the goal is to have a patient on a Disease-Modifying Antirheumatic Drug (DMARD) quickly, as these drugs slow down the disease process and help prevent further joint damage. DMARDs should be started within how many months of diagnosis?
A. 1 month
B. 2 months
C. 3 months
D. 6 months
E. 12 months
C.
JC has rheumatoid arthritis and has been taking Enbrel for 1 year. He continues to experience daily symptoms and poor quality of life. Which drug could be added to his rheumatoid arthritis regimen? (Select ALL that apply.)
A. Humira
B. Rheumatrex
C. Orencia
D. Motrin
E. Rituxan
B, D. Rheumatrex and Motrin can be used concurrently in this patient. The patient is already on Enbrel and should avoid concurrent use of another biologic agent. Concurrent use of biologics can increase risk of serious infection.
Rheumatrex (methotrexate)
Motrin (ibuprofen)
Humira (adalimumab): Anti-TNF
Orencia (abatacept): binds CD80 and CD86, inhibiting T cells
Rituxan (rituximab): CD20 inhibitor
Madeline is complaining of a grating pain in her right knee. She states that her knees hurt on and off, but the right knee pain is much worse. She does not have morning fatigue. Her finger joints are not swollen. Madeline is 60 inches tall and weighs 186 pounds. She is not physically active. Choose the most likely diagnosis for the cause of pain:
A. Rheumatoid arthritis
B. Osteoarthritis
C. Gouty arthritis
D. Ankylosing spondylitis
E. Fibromyalgia
B. Rheumatoid arthritis will present as bilateral (both sides)-this patient has a unilateral (right side only) presentation. She is overweight and not physically active. The extra weight will put pressure on her knee joints, leading to damage. She would not be expected to have much muscle mass to support the joints due to the low level of physical activity.
RA (rheumatoid arthritis) vs OA (osteoarthritis)
RA: Affects BOTH sides of body in JOINTs, SYMMETRICAL, CHRONIC, PROGRESSIVE, affects entire body (SYSTEMIC), can cause vascular complications like MI because vessels become more stiff as well, leads to cartilage and bone destruction
can be mild at diagnosis, or multiple places flare up
OA: Could be bilateral, but usually one joint or multiple joints or one side, not symmetrical
A patient will begin hydroxychloroquine therapy. Choose the correct counseling statements: (Select ALL that apply.)
A. You should not become pregnant while taking this medication
B. You will need eye exams when receiving this medication.
C. Stomach upset can occur; take the tablet with food or milk.
D. You should notice symptom improvement within 2-3 days of starting therapy.
E. Contact your doctor if you have any visual changes, including blurred vision and sensitivity to light.
B, C, E. Visual problems, including retinopathy, are a concern with the use of hydroxychloroquine. This is a commonly used medication. Counsel to take with food or milk to decrease GI upset. In addition to RA, it is used for lupus.
hydroxychloroquine (Plaquenil): more for mild-moderate disease, can be used in combo
Dosed daily, take with food or milk
Pregnancy (C)
SE: GI upset, NVD, abdominal pain, vision changes (eye exam), pigmentation of skin and hair
CI: retinopathy
A patient is receiving Humira. Choose the correct statement/s regarding Humira: (Select ALL that apply.)
A. The medication is injected intravenously, once weekly or every other week.
B. Humira can suppress tuberculosis infections.
C. The generic is adalimumab.
D. It can be administered in combination with methotrexate.
E. It can be administered in combination with infliximab.
C, D. Similar to etanercept (Enbrel) this medication comes in a syringe (or vial) and is administered by subcutaneous injection. All drugs in this group can reactivate TB infections, and can cause other serious infections since they suppress the immune system. Patients should never receive more than 1 biologic agent concomitantly.
Anti-TNF
etanercept (Enbrel) – Anti-TNF, 50mg SC weekly
adalimumab (Humira): 40mg SC every other week, or weekly when without MTX
infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions
certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks
golimumab (Simponi): 50mg SC monthly, IV requires filter
KT has rheumatoid arthritis, hypertension, and asthma. She takes Enbrel, Tylenol, hydrochlorothiazide, Flovent, Proair HFA, and a daily multivitamin. Which vaccines can she receive at this time?
A. Zostavax
B. Fluzone
C. Engerix-B
D. Pneumovax
E. FluMist
B, C, D. Because TNF inhibitors work by blocking the immune system, they lower the patient’s ability to fight infection. Therefore, patients using TNF inhibitors should not be given live vaccines such as Flumist or Zostavax.
Enbrel (etanercept) - Anti-TNF, 50mg SC weekly
Biologic DMARDs
2 categories: TNF and non-TNF
Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line
Non-TNF inhibitors: 2nd line
Warnings: serious infections and malignancies (remember LIST)
L – lymphomas, I – infections , S – skin cancer, T – tuberculosis
Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)
No live vaccines
Antibody induction: may develop antibodies against these agents which reduces efficacy
Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)
Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs
A patient is taking hydroxychloroquine, methotrexate, magnesium, calcium, raloxifene and atorvastatin. She reports that her mouth, including her gums, are sore. Upon inspection, the oral cavity appears inflamed. This complaint is most likely due to the following medication:
A. Hydroxychloroquine
B. Methotrexate
C. Raloxifene
D. Atorvastatin
E. Magnesium
B. When used weekly for rheumatoid arthritis, the most common side effects of methotrexate are stomatitis, nausea and diarrhea. RA patients can also experience liver toxicity, especially with long-term use. Chemotherapy doses, which are typically given IV, are more likely to result in liver, pulmonary or other toxicities, including bone marrow suppression. Stomatitis also occurs with IV administration.
Non-biologic DMARDs
methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD
Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose
SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, alopecia (using auto-injector can bypass GI problems)
CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)
Folic acid supplementation on the day after MTX
In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.
