Chapter 46: Systemic Steroids & Autoimmune Conditions Flashcards
1
Q
Which steroid drug mimics aldosterone
A
fludrocortisone
2
Q
Fludrocortisone is FDA approved for ____ & used off-label for ____
A
Addison’s disease
Orthostatic hypotension
3
Q
Steroids such as prednisone and hydrocortisone have more ____ activity, which has more ____ effects
A
glucocorticoid; anti-inflammatory
4
Q
Systemic steroids can cause the adrenal gland to stop producing ____, which is called ____
A
cortisol; suppression of the HPA axis
5
Q
Cushing’s Syndrome develops when the adrenal gland produces too much ____, or when exogenous (i.e., taken as a drug) steroids are taken in high doses
A
cortisol
6
Q
In Addison’s disease:
A
the adrenal gland is not making enough cortisol
7
Q
If exogenous steroids are stopped suddenly, it can cause
A
Addisonian Crisis, which can be fatal
8
Q
What are ways to reduce systemic steroid risks
A
- use alternate day dosing
- for a condition in the gut, use a steroid with low systemic absorption, such as Budesonide
- For joint inflammation, inject into the joint so the drug stays local
- For treatment of asthma, use inhaled steroids that mostly stay in the lungs
- For conditions that require long-term steroids, use the lowest possible dose for the shortest possible time
9
Q
Rank steroids from least to most potent
A
Remember: Cute Hot Pharmacists and Physicians Marry Together & Deliver Babies Cortisone Hydrocortisone Prednisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone
10
Q
What is the brand name for dexamethasone
A
DexPak 6, 10 or 13 day, Decadron
11
Q
What is the brand name for hydrocortisone
A
Solu-Cortef
12
Q
What is the brand name for methylprednisolone
A
Medrol, Solu-Medrol
13
Q
What is the brand name for prednisone
A
Deltasone
14
Q
What is the brand name for prednisolone
A
Millipred, Orapred ODT
15
Q
What is the brand name for Triamcinolone
A
Kenalog
16
Q
If taking steroids once daily, take between ____ to mimic the natural diurnal cortisol release
A
7-8 AM
17
Q
Should steroids be taken with or without food?
A
With food
18
Q
Steroid-induced medical conditions include:
A
- diabetes
- hypertension
- glaucoma
- psychiatric conditions
19
Q
Must taper steroids if taking longer than ___ days
A
14
20
Q
Short-term side effects of steroids can lead to:
A
increased appetite/weight gain, emotional instability, insomnia
21
Q
Cortisone is a prodrug of
A
cortisol
22
Q
prednisone is a prodrug of
A
prednisolone
23
Q
A patient is immunosuppressed when using >/= __ mg/kg/day or >/= __ mg/day of prednisone or prednisone equivalent
A
2; 20
24
Q
Common way to taper steroids
A
Reduce the dose by 10-20% every few days. Tapers can last 7-14 days
25
Nonspecific lab blood tests that can be useful in detecting inflammation include:
ESR, C reactive protein, rheumatoid factor, and antinuclear antibody
26
The use of strong immunosuppressants can increase the risk of certain conditions including:
- Reactivation of TB and Hep B and C
- Viruses
- Lymphomas and certain skin cancers
- Infections
27
_____ is consistent with a rheumatoid arthritis diagnosis
Bilateral, symmetrical disease
28
What are common symptoms of RA
Joint swelling, pain, stiffness, bone deformity
29
Which lab tests are useful to help diagnose RA
rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA)
30
Patients with symptomatic RA should be started on ____, regardless of the severity
DMARD
31
What is the preferred initial DMARD for most patients with RA
Methotrexate
32
Which class of medication are used for RA flares
steroids (low-dose)
33
What is the brand name for MTX oral tab
Trexall
34
What is the brand name for MTX SC auto-injectors
Otrexup and Rasuvo
35
What is the MOA of MTX
Irreversibly binds and inhibits dihydrofolate reducatse, inhibiting folate
36
What is the dosing for MTX for RA
7.5-20 mg once weekly (PO, SC, IM)
37
Why should MTX not be dosed daily in RA
Numerous incidences of ADE (e.g, mouth sores, intestinal bleeding, liver damage) have occurred in patients taking daily
38
Boxed warnings for MTX
hepatotoxicity, myelosuppression, mucositis/stomatitis, pregnancy
39
What should be monitored when using MTX
CBC, LFTs, CXR, hepatitis B and C serologies
40
Why is folate given with MTX
To decrease hematological, GI and hepatic SE
41
Brand name for hydroxychloroquine
Plaquenil
42
Warning for hydroxychloroquine
irreversible retinopathy
43
When would you use hydroxychloroquine over MTX
If there is a concern for liver disease
44
What is a CI for sulfasalazine
sulfa or salicylate allergy
45
What color can sulfasalazine turn the skin/urine
yellow-orange
46
What is the MOA for leflunomide
Inhibits pyrimidine synthesis resulting in anti-proliferative and anti-inflammatory effects
47
Boxed warnings for leflunomide
Do not use in pregnancy (teratogenic); hepatotoxicity
48
What are the accelerated drug elimination options for leflunomide
1. Cholestyramine 8 grams PO TID x 11 days
| 2. activated charcoal suspension 50 grams po Q12H x 11 days
49
If pregnancy is desired when using leflunomide, you must wait ___ after discontinuation or use accelerated drug elimination procedures
2 years
50
Boxed warnings for Janus Kinase Inhibitors
Serious infections including TB, fungal, viral, bacterial and others; malignancies; thrombosis
51
What medication classes cannot be used with janus kinase inhibitors
biologic DMARDs or potent immunosuppressants
52
Renal elimination of MTX is decreased by
aspirin and NSAIDs
53
T/F: needles need to be purchased separately with anti-TNF biologic DMARDs
F. They are included
54
Etanercept brand name
Enbrel
55
Adalimumab brand name
Humira
56
Infliximab brand name
Remicade
57
Certolizumab pegol brand name
Cimza
58
Golimumab brand name
Simponi
*Goli is a simp*
59
What medication can anti-TNF biologic DMARDS be given with
MTX. DO NOT USE WITH OTHER BIOLOGIC DMARDs OR LIVE VACCINES
60
Enbrel dosing frequency
SC weekly
61
Humira dosing frequency
SC every other week
62
Infliximab is given via which route
IV
63
Cimzia dosing frequency
SC every other week
64
Simponi dosing frequency
SC monthly; can also be given IV
65
Boxed warning for anti-TNF biologic DMARDS
serious infections; screen for latent TB & treat if needed; lymphomas and other malignancies
66
Warnings for anti-TNF biologic DMARDS
Can cause demyelinating disease, hepatitis B reactivation, HF, hepatotoxicity, and lupus-like syndrome
67
Infliximab (Remicade) requires a filter and is only table in ____
normal saline
68
Which anti-TNF biologic DMARD causes infusion reactions
Infliximab (Remicade)
69
Which anti-TNF biologic DMARD causes delayed hypersensitivity reactions
Infliximab (Remicade)
70
Rituximab brand name
Rituxan
71
MOA of retuximab
Depletes CD20 B cells
72
How is Rituxan given
IV
73
What premedications should be given with Rituxan
steroid, APAP and antihistamine
74
Boxed warning for Rituxan
infustion-related reactions usually with first infusion, HBV reactivation
75
T/F: Rituximab can be given with other biologic DMARDs or live vaccines
False
76
Otrexup & Rasuvo (methotrexate single-use auto-injectors) should be administered in what parts of the body
abdomen or upper thigh only
77
etanercept (Enbrel) and adalimumab (Humira) can be stored at room temperature for a max of ___ days
14
78
Where can adalimumab (Humira) be injected
abdomen or thigh
79
Where can etanercept (Enbrel) be injected
abdomen, thigh or upper arm
80
Where can golimumab (Simponi) be injected
abdomen, thigh or upper arm
81
SLE is most common in which gender/ethnicities
women of AA and Asian descent
82
Most common symptoms of SLE
fatigue, depression, anorexia, weight loss, muscle pain, malar rash (butterfly rash), photosensitivity, and joint pain and stiffness
83
What condition develops in over 50% of patients with SLE
lupus nephritis
84
Which common lab findings are associated with a SLE diagnosis
positive ANA and positive anti-ssDNA and anti-dsDNA
85
Treatment for SLE can take up to ____ to see max benefit
6 months
86
What drugs are used for chronic SLE
hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate mofetil and cyclosporine
87
Belimumab (Benlysta) used for SLE has what warnings
serious infections; do not give with other biologic DMARDs or live vaccines
88
Belimumab (Benlysta) used for SLE has a lower response rate for which population
AA
89
Early symptoms of multiple sclerosis includes
fatigue, numbness, and blurred vision
90
Glatiramer acetate brand name
Copaxone
91
Glatiramer acetate warning
chest pain
92
Glatiramer acetate side effects
injection site reactions, flushing, diaphoresis, dyspnea
93
What is the preferred agent if treatment of MS is required during pregnancy
Glatiramer acetate
94
How is Glatiramer acetate dosed
20 mg SC daily or 40 mg SC 3 times per week
95
How is interferon beta-1a (Avonex, Rebif) dosed
Avonex: IM weekly
Rebif: SC 3 times per week
96
How is interferon beta-1b (Betaseron, Extavia) dosed
SC every other day
97
How is peginterferon beta-1a (Plegridy) dosed
SC every 14 days
98
What are warnings for interferon beta products used in MS
psych disorders (depression/suicide), injection site necrosis, increased LFTs, thyroid dysfunction (hyper and hypo)
99
What is a SE for interferon beta products used in MS
Flu-like symptoms
100
T/F: Make sure to expel the small air bubble in prefilled syringes of interferon beta products
False; you will lose the dose
101
Some formulations of interferon beta products used in MS contain ____
albumin
102
T/F: All interferon beta products used in MS (except Betaseron and Extavia [interferon beta-1b]) must be refrigerated. If taken out of the refrigerator, you do not need to let it stand at RT prior to injection
False; you should let it sit out at RT
103
What is a CI of teriflunomide (Aubagio), an oral immunomodulator
pregnancy
104
Fingolimod, an oral immunomodulator, can cause ____ and the patient must be monitored for at least ___ after the first dose
bradycardia; 6 hours
105
Fingolimod, an oral immunomodulator, is CI in most patients with history of
CVD or stroke
106
Fingolimod, an oral immunomodulator, requires ___ at baseline and at end of initial observation
ECG
107
Fingolimod and Siponimod, oral immunomodulators used in MS, have significant ADE for
macular edema, hepatotoxicity, and myelosuppression
108
T/F: Diemthyl fumarate and Diroximel fumarate, oral immunomodulators used in MS, CANNOT be crushed, chewed or sprinkled onto food
True
109
Siponimod, an oral immunomodulator, is CI with
CYP2C9*3/*3 genotype
110
Natalizumab brand name
Tysabri
111
Natalizumab boxed warning
PML; only available through the REMS TOUCH Prescribing Program
112
Drugs commonly used for symptom control in MS include:
anticholinergics for incontinence, laxatives for constipation, muscle relaxants for muscle spasms, analgesics for muscle spams and pain, and propranolol for tremor
113
Which medication class (and specific medication) is used commonly to prevent Raynaud's Phenomenon
CCBs; commonly nifedipine
114
Which drugs can cause or worsen Raynaud's
BB, Bleomycin, cisplatin, sympathomimetics (from vasoconstriction) like amphetamines, PSE and illicit drugs
115
Patients with celiac disease have gluten intolerance. Pharmacists should look at package inserts of medications to look for the excipient components. What words should the pharmacist look for?
starch (corn, potato, tapioca, or wheat). Wheat, barley and rye are the gluten proteins
116
Which drugs can worsen or unmask myasthenia gravis
```
Antibiotics: AMG and quinolones
Mg salts
select antiarrhythmics
BB & CCB
Select antipsychotics
Muscle relaxants
Local anesthetics
```
117
MOA of pyridostigmine
block the breakdown of ACh
118
Sjogren's syndrome is characterized by
severe dry eyes and dry mouth
119
What OTC products can be used for dry eyes in Sjogren's syndrome
artificial teardrops (Systane, Refresh, Clear Eyes, and Liquifem)
120
Cyclosporine emulsion brand name
Restasis
121
Side effect of Restasis
burning of eyes
122
Lifitegrast Brand name
Xiidra
123
Side effect of Xiidra
unusual taste
| *remember xii has unusual taste*
124
What rx drugs can provide treatment for dry mouth in Sjogren's syndrome
muscarinic agonists such as pilocarpine or cevimeline. These are CI in pts with uncontrolled asthma and narrow-angle glaucoma
125
What non-drug treatment can help mild-moderate psoriasis symptoms?
UVB phototherapy
126
If steroids, vitamin D analogues, anthralin, retinoids, salicylic acid, coal tar and moisturizers fail for treatment of psoriasis, what can be used
topical calcineurin inhibitors
