Chapter 46: Systemic Steroids and Autoimmune Conditions Flashcards
Cushing’s syndrome
When the adrenal gland produces too much cortisol or if exogenous steroids are taken in doses higher than endogenous cortisol
Addison’s disease
Adrenal gland is not making enough cortisol. Can cause Addison’s crisis if steroids are stopped suddenly and cause volume depletion and hypotension which can be fatal
Steroids Least Potent to Most Potent
“Cute Hot Pharmacists and Physicians Marry Together and Deliver Babies”
Cortisol Hydrocortisone Prednisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone
Steroid Dose Equivalencies to Prednisone
Cortisol 25mg Hydrocortisone 20mg Prednisone 5mg Prednisolone 5mg Methylprednisolone 4mg Triamcinolone 4mg Dexamethasone 0.75mg Betamethasone 0.6mg
Rheumatoid Arthritis Presentation
Bilateral, symmetrical joint pain. Stiffness and pain are worse after rest and “morning stiffness” is common.
Anti-citrullinated peptide antibody (ACPA) and rheumatoid factor (RF) are useful for diagnosis
RA Drug Tx
Symptomatic RA should be started on a disease-modifying antirheumatic drug (DMARD) regardless of the severity of disease
RA Preferred Initial Therapy
Methotrexate
Low-dose steroids (<=10mg/day) can be added for moderate to severe disease
Methotrexate Dosing
Trexall is po tab
7.5-20mg po once weekly (IM, SC, PO)
MTX Boxed Warning
Hepatoxicity, myelosuppression, mucositis/stomatitis, pregnancy (teratogenic)
MTX Monitoring and Notes
CBC, LFTs, chest x-ray, hep b and c serologies
Notes: can give folate to decrease hematological, GI, and hepatic SE
Hydroxychloroquine Warnings and Monitoring
Warnings: irreversible retinopathy
Monitoring: eye exam q3 months
Sulfasalazine CI
Aspirin or Sulfa allergy
Can cause yellow-orange coloration of skin/urine
Leflunomide MOA
inhibits pyrimidine synthesis resulting in anti-proliferative and anti-inflammatory effects
Leflunomide Boxed Warnings and Notes
Boxed warnings: Do not use in pregnancy (teratogenic), hepatotoxicity
CI: pregnancy
Notes: Accelerated drug elimination with cholestyramine.
Must have negative pregnancy tests and use 2 forms of birth control during tx. Must wait 2 years after d/c to get pregnant or do accelerated drug elimination
Janus Kinase Inhibitors (JAK) MOA
Inhibit JAK enzymes which stimulate immune cell function
JAK inhibitors Drugs
Tofacitinib, Baricitinib, Upadacitinib
JAK inhibitors boxed warnings
Serious infections (TB, fungal, viral, OI etc)
Increased risk for malignancies (lymphomas)
Increased risk for thrombosis
Do not use with biologic DMARDs
Anti-TNF Biologic DMARDs and pregnancy
Tumor necrosis factor alpha inhibitors
All have pregnancy warnings and registry due to unknown effects
Etanercept
Enbrel SC weekly
+/- MTX
Adalimumab
Humira SC QOW
+/- MTX
Infliximab
Remicade IV only
Only stable in NS, must use filter
Infusion reactions and delayed hypersensitivity rxns
+ MTX
Certolizumab pegol
Cimzia SC QOW
+/- MTX
Golimumab
Simponi SC qmonthly
IV requires a filter
+MTX
Anti-TNF Biologic DMARDs Boxed Warnings and Warnings
Boxed: serious infections, latent tb (treat it), lymphomas and other malignancies
Warnings: Can cause demyelinating disease, HBV reactivation, HF, hepatotoxicity, lupus-like symptoms
Do not use with other biologic DMARDs or live vaccines
Anti-TNF Biologic DMARDs Monitoring and Notes
Monitoring: prior to initiation TB test and HBV; routine look for signs of infection
Notes: Do not shake or freeze, requires refrigeration. MTX is 1st line and biologics are add on but if initial presentation is severe can be use an initial therapy
Rituximab
Non-TNF Biologic DMARD
Works by depleting CD20 B cells
+MTX
Premedicate with steroid, apap, and an antihistamine
Rituximab Boxed Warnings
Serious and fatal infusion reactions, HVB reactivation, screen for HBV and HCV
Do not give with other Biologic DMARDs or live vaccines
Systemic Lupus Erythematosus Clinical Presentation
- Fatigue
- Depression
- Anorexia
- Weight loss
- Muscle pain
- Malar (butterfly) rash
- Photosensitivity
- Joint pain and stiffness
SLE Labs
Anti-ssDNA
Anti-dsDNA
ANA (antinuclear antibodies)
Drugs that cause DILE
“My Pretty Malar Marking Probably Has A TransIent Quality”
Methimazole Propylthiouracil Methyldopa Minocycline Procainamide Hydralazine Anti-TNF agents Terbinafine Isoniazid Quinidine
SLE 1st line Tx
- Hydroxychloroquine
- Cyclophosphamide
- Azathioprine
- Mycophenolate mofetil
- Cyclosporine
Belimumab
Benlysta
FDA approved for tx of Lupus
Warnings: serious infections, do not give with other biologic DMARDs or live vaccines
Voclosporin
Lupkynis
FDA approved for lupus and lupus nephritis
Warnings: serious infections and malignancies, nephrotoxicity, hypertension, do not give with live vaccines.
SE: HA, HTN, diarrhea, renal impairment
Multiple Sclerosis (MS) background
Chronic progressive autoimmune disease, where the patients immune system attacks the myelin sheath, the fatty substance that surrounds and insulates nerve fibers of the brain and spinal cord axons.
MS Clinical Presentation
Early symptoms include: fatigue, numbness, and blurred vision.
As condition worsens deteriorating cognitive fx, muscle spasms, pain, incontinence, walking with gait instability
Glatiramer acetate
Copaxone 20mg SC qd or 40mg SC TIW
For relapsing MS
Glatiramer acetate Warnings, SE
Warnings: chest pain
SE: injection site rxns, flushing, diaphoresis, dyspnea
Note: preferred tx if necessary during pregnancy
Interferon beta 1a dosing
Avonex: 30mcg IM qw
Rebif: 44mcg sc tid
Interferon beta 1b dosing
0.25mg sc QOD
Peginterferon beta 1a dosing
125mg sc q14 days
Interferon Beta Products warnings and notes
Warnings: psychiatric disorder, injection site necrosis, increased LFTs, thyroid dysfunction,
SE: flu-like symptoms
Notes: If refrigerated let stand at room temp prior to injection. Do not expel air bubble
Sphingosine 1-phosphate receptor modulator
-imod
Caution with other drugs that slow HR, monitor CBC, macular edema, eye exam, LFTs
MS can become worse when tx is stopped
Nuclear Factor Activators
Dimethyl fumarate
Diroximel fumarate
Do not crush, chew or sprinkle cap contents on food
Natalizumab
Tysabril (MAB)
Boxed warmings: progressive multifocal leukoencephalopathy
Alemtuzumab
Lemtrada
Recombinant humanized MAB
REMs program
Raynaud’s Phenomenon
Condition triggered by cold and/or stress leading to vasospasm in the extremities (fingers/toes) that causes the skin to turn white and then blue
Raynaud’s tx
Includes vasodilation CCB (nifedipine)
Drugs that cause or worsen Raynaud’s
BB
Bleomycin, cisplatin
Smypathomimetics (amphetamines, cocaine)
Gluten found in
Wheat, barley, rye
Celiac Disease symptoms
Diarrhea, abdominal pain, bloating, and weight loss
Myasthenia Gravis Background
Attacks the connection between nerves and muscle resulting in weakness in skeletal muscle. In most cases immune system targets ACh receptors. Symptoms include eyes/vision
Pyridostigmine
Blocks breakdown of ACh
Can cause cholinergic effects (salivation, lacrimation etc)
Sjogren’s Syndrome Background
Commonly characterized by dry eyes and mouth. Complications include dental cavities, corneal ulcerations, and chronic oral infections
Restasis
Cyclosporine emulsion
Can cause ocular burning
Lifitegrast
Xiidra
SE: unusual taste
Non-pharm for dry mouth
- sugar free chewing gum (xylitol)
- Lozenges
- Daily rinses with antimicrobial mouthwashes
Psoriasis background
Most common is plaque psoriasis appears as raised, red patches covered with a silvery white buildup
Non-pharm for Psoriasis
UV light exposure causes activated t-cells in the skin to die
Topicals for Psoriasis
Include steroids, vitamin d analogs, etc if these fail topical CN inhibitors (protopic and elidel) can be tried
