Chapter 8

Question 1

Azathioprine & Allopurinol

Answer 1

Reduce dose of Azathioprine when given with allopurinol- risk of bone marrow suppression

Question 2

Azathioprine & mycophenolate Side effect

Answer 2

Red cell aplasia

• dose reduction
• discontinuation

Question 3

What side effects can happen at early stages of treatment with Azathioprine in RA?

Answer 3

Nausea, vomiting and diarrhoea

If these happen, discontinue

Question 4

Azathioprine

Monitoring requirements

Answer 4

• FBC for 4 weeks, then every 3 months
• monitor toxicity throughout treatment
• signs of myelosuppression

Question 5

TPMT activity &

antiproliferative drugs

Answer 5

Tiopurine Methyltransferase (TPMT) activity should be measured before treatment and if it is reduced then patients are at risk of myelosuppression

Question 6

Mycophenolate

Answer 6

Has more selective mode of action compared to Azathioprine (antiproliferative drugs)

Question 7

Which ones are antiproliferative drugs? What advice need to be given to patients?

Answer 7

• Azathioprine and Mycophenolate

- Advice - bone marrow suppression

Question 8

Concurrent administration of immunosuppressants - risk?

Answer 8

• recurrent infection

- respiratory symptoms (cough and dyspnoea)

Question 9

Pregnancy prevention & Mycophenolate

Answer 9

• exclude pregnancy before and during treatment
• use two effective methods of contraception during treatment and 6 weeks after for women
• and for 90 days after discontinuation for men

Question 10

Ciclosporin (High risk)

Answer 10

• potent immunosuppressant
• nephrotoxic
• requires loading dose
• prescribe by brand name

Question 11

Ciclosporin & sunscreen

Answer 11

Advice patient to avoid exposure to UV light (sunlight) and use sunscreen

Question 12

Monitoring requirements of ciclosporin

Answer 12

• rental function
• liver function
• BP
• FBC
• dermatological and physical examination
• blood lipids
• serum electrolytes (potassium & magnesium)

Question 13

Ciclosporin contraindications

Answer 13

• must not have live vaccines
• avoid grapefruit juice
• avoid high potassium diet
• oral solutions can be taken with apple or orange juice to improve taste

Question 14

Ciclosporin interactions

Answer 14

• ciclosporin & statins -> myopathy
• ciclosporin & colchicine -> nephrotoxicity and myotoxicity
• ciclosporin & digoxin -> increased risk of toxicity
• risk of nephrotoxicity +NSAIDs
• increased plasma concentration (clarithromycin, erithromycin, antifungals, metoclopramide, verapamil, & tacrolimus)
• decreases plasma concentration (carbamazepine, orlistat, SJW, phenytoin, phenobarbital, rifampicin)
• risk of hyperkalaemia (ACE, ARBs, aldosterone antagonists