Autoimmunity and Corticosteroids Flashcards
What is autoimmunity?
How is it diagnosed?
Aetiology?
The action of the body’s immune system against part of self:
- organ specific e.g. RA
- organ non-specific e.g. SLE
Diagnosis: clinical and auto-antibodies
Aetiology:
- genetics - reduction in number and function of T cells
- environmental trigger
What are the principles of management of autoimmune diseases?
What is the pharmacological management?
- early diagnosis
- symptom control - pain
- drugs - treat disease process/pain
- others e.g. physiotherapy
Pharmacological management:
- analgesics/NSAIDs - inadequate as feature of underlying disease process will remain unchecked leading to further damage and disability
- corticosteroids - locally by injection, systemic to manage flare ups (ideally not used long term)
- DMARDs - disease modifying anti-rheumatic drugs - suppress immune system, slow disease progression
- biologics - proteins produced by living organisms, given by IV injection, target one aspect of immune system
What is the role of corticosteroids?
List some types of corticosteroids:
What are some warnings of oral form of steriods?
Corticosteroids suppress immune system, decreasing autoimmune response and reduce inflammation
- hydrocortisone/triamcinolone intra-articular injection
- prednisolone oral: start on high dose, tapering off dose, maintenance dose, DMARD started
Warnings - gastric bleeding, mania, suicidal thoughts
What are some side effects of corticosteroids?
Long term effects?
Oral issues?
Side effects - hyperglycaemia, osteoporosis, weight gain, cushings syndrome, peptic ulcers
Long-term - monitor BP, osteoporosis prophylaxis (Vit D, bisphosphonates)
Oral issues:
- increased susceptibility to infection
- candidiasis
- MRONJ
- prophylaxis for pts on long term steroids but discuss with GP
List some points regarding DMARDs:
- part of a protocol of disease management
- most effective with early diagnosis and early introduction of the drug
- monotherapy or combination therapy
- escalate to therapeutic doses as quickly as possible
- with or w/out corticosteroids
- refer early to secondary care
- most require regular blood tests e.g. FBC, LFTs, renal function
Name some DMARDs:
- azathioprine
- ciclosporin
- cyclophosphamide
- gold
- hydroxychloroquine
- leflunomide
- methotrexate
Which conditions can be treated with DMARDs in general medicine?
- rheumatoid arthritis
- psoriatic arthritis and psoriasis
- SLE
- juvenile idiopathic arthritis
- systemic sclerosis
- sjogrens syndrome
- inflammatory bowel syndrome
- ankylosing spondylitis
Which conditions are treated by DMARDs in oral medicine?
- lichen planus
- mucous membrane pemphigoid
- pemphigus vulgaris
- behcets disease
- erythema multiforme
Which pre-treatment checks are required before prescribing DMARDs?
What is a common side effect of DMARDs and how may this present?
- baseline blood investigations
- consider screening for viral infections before commencing e.g. HIV, HepB, HepC, depending on risk factors
- consider chest x-ray before commencement - check for signs of TB
Side effects: bone marrow suppression - anaemia, red cell aplasia, neutropenia, thrombocytopenia, leucopenia
Methotrixate - oral ulceration
Increased susceptibility to infection
What are biologic drug groups?
- cytokines e.g. erythropoetin
- fusion proteins
- monoclonal antibodies
Target one specific part of the immune system, incontrast to DMARDs which suppress the entire immune system
What are monoclonal antibodies used for?
- for autoimmune diseases and cancer
- rapidly developing field
Autoimmune diseases:
- for use in patients who have had failed therapy with at least 2 DMARDs
- pts with severe RA also licensed for first line treatment
- may be used in combination with a DMARD e.g. methotrixate
List some examples of fusion proteins used for autoimmune diseases:
Monoclonal antibodies:
Anti-TNF - etanercept: RA, psoriasis, psoriatic arthritis, ankylosing spondylitis
T-cell activation inhibitors - abtacept
Monoclonal antibodies - end in ‘MAB’
TNF alpha inhibitors:
- adalinumab
IL-6 receptor blockers
Interleukin inhibitors
B-cell activation inhibitors
anti-B lymphocytes - rituximab
How are patients monitored when taking monoclonal antibodies?
- FBC, U&E, LFT
- lipid profile
- Hep B, Hep C TB screening
Dental considerations for patients who take biologics:
- Increased risk of infection - discontinued in the presence of serious infection
- Thrombocytopenia, neutropenia
- Side effects: heart failure, lupus like, demyelination, skin cancer, uveitis
- dentally fit before commencement
- consider liver and renal function when prescribing
- MRONJ - RANKL inhibitors (denosumab) and anti-angiogenic drugs
- mucosal disease as a side effect of those used to treat cancers
