46. Systemic Steroids + Autoimmune Conditions (not completed)

Question 1

Fludocortisone mimics ___. It has mineral corticoid acitivty which is used to maintain a balance of ___. Helps keep BP stable.

Answer 1

Aldosterone
Water and electrolytes

Question 2

Fludrocortisone is FDA approved for ___ but also used off-label for ___

Answer 2

Addison’s disease
Orthostatic hypotension

Question 3

Other commonly used steroids (e.g. prednisone, hydrocortisone) have more __ activity which has more anti-inflammatory effects

Answer 3

Glucocorticoid

Question 4

When are steroids typically used

Answer 4

Inflammatory conditions
Immune suppression post-transplant
Adrenal insufficiency (to replace endogenous steroids that the adrenal gland is not producing enough of)

Question 5

Systemic steroids can cause the adrenal gland to stop producing ___ d/t feedback inhibition. This is called suppression of the ____

Answer 5

Cortisol
Hypothalamic pituitary-adrenal (HPA) axis

Question 6

T/F: when long-term steroids are d/c, they can be stopped immediately

Answer 6

False - taper off to give adrenal gland time to resume cortisol production

Question 7

___ can develop when the adrenal gland produces too much cortisol or if exogenous steroids are taken in doses higher than normal amt of endogenous cortisol

Answer 7

Cushing’s syndrome

Question 8

____ can be thought of the opposite of Cushing’s syndrome. In this condition, the adrenal gland is not making enough ____. If exogenous steroids are stopped suddenly, it can cause an ____, which can be fatal.

Answer 8

Addison’s disease
cortisol
“Addisonian Crisis”

Question 9

Ways to reduce systemic steroid risks

Answer 9

Alternate day dosing
Localize: For joint inflammation, Inject into join (localize) // for asthma, use ICS
For condition in the gut, us steroid with low systemic absorption such as budesonide (Entocort EC)
For conditions that require long-term use, use lowest possible dose for shortest possible time

Question 10

Long-term effects of steroids (e.g. Cushing’s Syndrome)

Answer 10

Psychiatric changes (anxiety, depression ,delirium, psychoses), HA, intracranial HTN, hypothyroidism
Glaucoma, cataracts
Acne
Fat deposits in face (moon face), abdomen, upper back (buffalo hump)
GI bleeding/esophagitis/ulcers
Pink-purple stretch marks (striae) on abdomen, thighs, breasts, and arms, think skin that bruises easily
Diabetes
Growth retardation, muscle wasting (thin arms and legs relative to rest of body)
Poor bone health
infection, impaired wound healing
Women only: hair growth on face/body (hisutism), irregular or absent menstrual periods

Question 11

Steroids least potent to most potent and dose equivalence

Answer 11

Cute Hot Pharmacists and Physicians Marry Together & Deliver Babies
Cortisone 25mg
Hydrocortisone (Solu-Cortef)20mg
Prednisone (Millipred, Orapred ODT) 5mg
Prednisolone (Deltasone) 5mg
Methylprednisolone (Medrol, Solu-Medrol) 4mg
Triamcinolone (Kenalog) 4mg
Dexamethasone (Decadron) 0.75mg
Betamethasone (Celestone) 0.6mg

Question 12

Short term side effects of systemic glucocorticoids (<1 month)

Answer 12

Increased appetite/weight gain, emotional instability (euphoria, mood swings, irritability) insomnia, increased intraocular pressure, fluid retention, indigestion, bitter taste, increased BP/BG with higher doses

Question 13

Cortisone is prodrug of ___

Answer 13

cortisone

Question 14

Prednisone is prodrug of ___

Answer 14

prednisolone

Question 15

Methylprednisolone formulations

Answer 15

Therapy pack (Medrol Dose Pack” and injection

Question 16

Warnings with systemic glucocorticoids

Answer 16

Adrenal suppression - HPA axes suppression may lead to adrenal crisis and death
If taking longer than 14 days, taper

Question 17

A patient is considered immunosuppressed when using ≥ ____/kg/day or ≥ ____/day of prednisone or equivalent for > 2 weeks

Answer 17

≥2mg/kg/day or ≥20mg/day for > 2 weeks

Question 18

Medrol Therapy Pack dosing

Answer 18

Tapered dosing with 4mg tabs x 21 over 6 days
Day 1: 2 tabs before breakfast, 1 tab after lunch, 1 tab after dinner, 2 tabs at bedtime
Day 2: 1 tab before breakfast, after lunch, and after dinner, 2 tabs at bedtime
Day 3: 1 tablet before breakfast, after lunch, after dinner, and at bedtime
Day 4: 1 tablet before breakfast, after lunch, and at bedtime
Day 5: 1 tablet before breakfast and at bedtime
Day 6: 1 tablet before breakfast

Question 19

Common symptoms of most autoimmune diseases include ___

Answer 19

fatigue, weakness, and pain

Question 20

Nonspecific lab blood tests can be useful in detecting inflammation including ___

Answer 20

erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF) and anti-nuclear antibody (ANA)

Question 21

The use of strong immunosuppressants can increase the risk of certain conditions including ____

Answer 21

Reactivation of tuberculosis and hep B or C (if present): testing (and treatment, if needed) must be done prior to starting immunosuppressive meds
Viruses: if live vaccine, must be given prior to start
Lymphomas and certain skin cancers: normally suppressed by competent immune system
Infections

Question 22

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disorder that primarily affects __. Other organs including kidneys, eyes, heart, and lungs can be affected.

Answer 22

joints

Question 23

Typical location of Rheumatoid arthritis

Answer 23

Bilateral, symmetrical disease is consistent with RA dx (in contrast to osteoarthritis (OA) which presents unilaterally)

Question 24

Classic symptoms of rheumatoid arthritis

Answer 24

Joint swelling
pain and stiffness worse after rest (“morning stiffness”, note: OA does not cause prolonged stiffness)
bone deformity
Others: weakness, difficult to move, edema, redness

Question 25

__ and __ are useful labs in diagnosing RA

Answer 25

Anti-citrullinated peptide antibody (ACPA)
Rheumatoid factor (RF)

Question 26

Patients with symptomatic RA should be started on ___ regardless of the severity of disease

Answer 26

disease-modifying antirheumatic drug (DMARD)

Question 27

DMARDs work via various mechanisms to _____

Answer 27

slow disease process and help further joint damage

Question 28

___ is the preferred initial therapy of most RA patients

Answer 28

Methotrexate (MTX) (Trexall)

Question 29

Never use 2 biologic DMARDs in combo d/t risk of ___

Answer 29

serious (fatal) infections

Question 30

Methotrexate dosing

Answer 30

7.5-20mg once weekly (PO, SC, IM) - safer to take as single dose (rather than divided oral dosages of 2.5mg Q12H x3 doses per week)
Never dose daily for RA (liver damage concern)

Question 31

MOA of methotrexate)

Answer 31

Inhibits dihydrofolate reductase, inhibiting folate

Question 32

Methotrexate formulations

Answer 32

Oral tab = Trexall
SC Auto-injectors = Otrexup, Rasuvo
Oral solution for ped pts = Xatmep

Question 33

Boxed warnings for methotrexate

Answer 33

Hepatotoxicity, myelosuppression, mucositis/stomatits, pregnancy
Others: acute renal failure, pneumonitis, GI tox, dermatologic reactions, malignant lymphomas, potentially fatal opportunistic infections
Renal and lung tox more likely when higher oncology doses

Question 34

Monitoring for Methotrexate

Answer 34

CBC, LFTs, chest X-ray, hep B and C (if at high risk)
Others: SCr, PFTs, TB test

Question 35

Folate can be given with methotrexate to decrease _____ side effects. Give 5mg po weekly on the day following MTX administration (some take 1mg daily on non-MTX days)

Answer 35

hematological, GI, and hepatic

Question 36

Hydroxychloroquine (Plaquenil) warnings

Answer 36

Irreversible retinopathy

Question 37

What Non-biologic DMARDs for RA can cause yellow-orange coloration of skin/urine?

Answer 37

Sulfasalazine

Question 38

Contraindication for sulfasalazine

Answer 38

Sulfa or salicylate allergy
GI or GU obstruction, porphyria

Question 39

MOA Leflunomide (Arava)

Answer 39

Inhibits pyrimidine synthesis&raquo_space; anti-proliferative and anti-inflammatory effects

Question 40

Boxed warning for Leflunomide (Arava)

Answer 40

Do NOT use in pregnancy (teratogenic) - test for prior to starting therapy
Hepatotoxicity - avoid in pre-existing liver disease or ALT >2ULN

Question 41

Contraindication for Leflunomide (Arava)

Answer 41

Pregnancy

Question 42

Leflunomide (Arava) pregnancy precautions

Answer 42

Must have neg pregnancy test prior and use 2 forms of birth control during treatment
If pregnancy is desired, must wait 2 years after d/c or accelerated drug elimination procedure

Question 43

Accelerated drug elimination options for leflunomide (Arava)

Answer 43

1. Cholestyramine 8g PO TID x 11 days (use 4g if 8g dose not tolerated)
2. Activated charcoal suspension 50mg PO Q12H x 11 days

Question 44

Boxed warning for Janus Kinase Inhibitors (Tofacitinib (Xeljanz), Baricitinib (Olumiant), Updacitinib (Rinvoq))

Answer 44

Serious infections
Malignancy
Thrombosis

Do NOT use with biologic DMARDs or potent immunosuppressants

Question 45

Concern with methotrexate with alcohol

Answer 45

Do not take with alcohol, increased risk of liver tox

Question 46

Concern with methotrexate with NSAIDs/aspirin

Answer 46

Decreased renal elimination of methotrexate&raquo_space; methotrexate toxicity