E4 Lupus Flashcards
jesus christ
3 main etiologies of lupus
genetics, hormonal, environment
T or F:
2nd degree relatives w/ lupus equates to 20 times more likely to develop it
false, 1st degree (dumb card im sorry)
hormonal etiology:
_______ production may modulate the incidence and severity SLE
estrogen
weird environmental factor contributing to lupus etiology
UV light, so sunscreen is imporTENT (also pesticides but she didnt talk about that as much)
DILE acronym for lupus
My
Pretty
Malar
Probably
Has
A
TransIent (capital I too)
Quality
drugs for that acronym for DILE
Methimazole
Propylthiouracil
Methyldopa
Minocycline
Procainamide
Hydralazine
Anti-TNF agents (infliximab and etanercept)
Terbinafine
Isoniazid
Quinidine
Which medication is most likely contributing to KB’s lupus-like syndromes?
Tylenol
Sprintec
Sertraline
Minocycline
minocycline
what is malar?
butterfly rash thing, resembles the wings, typically on face and shit i think
2 musculoskeletal s/sxs
arthralgias and myalgias
mucocutaneous s/sxs (5)
butterfly rash
photosensitivity
ulcers
discoid rash
raynauds pheno
1 ophthalmologic sx of lupus
lupus retinopathy (is this different than other retinopathies lol)
1 renal sx lupus
lupus nephritis*
3 pulmonary sxs lupus
dyspnea
pleuritis
pleural effusion
thrombosis sx lupus
antiphospholipid antibodies (say that 5 times fast)
immunologic sx lupus
autoantibodies
What is a classic skin manifestation of lupus?
A. Butterfly-shaped rash on the face
B. Blisters on the hand
C. Scaling on the scalp
D. Darkening around the eyes
A
Which of the following is a common trigger for lupus flare-ups?
A. Regular exercise
B. High sodium intake
C. Sun exposure
D. High cholesterol
C
2 very important diagnostic tools for lupus
SLICC
EULAR/ACR
SLICC:
Must meet ≥ __ total features with 1 from each group
OR?
4
or biopsy proving lupus nephritis (ANA+ and Anti-dsDNA+)
EULAR/ACR:
Patient’s score is ≥ __ AND at least 1 clinical criterion is fulfilled
10
T or F:
EULAR/ACR
Only the highest-weighted criterion score within a single domain is used
true
4 “very important” key labs for lupus
- Anti-Nuclear Antibody (ANA)
- Anti-double-stranded DNA (Anti-dsDNA)
- Anti-Smith Antibody (Anti-SM)
- Antiphospholipid antibody
not specific for diagnosis:
A. ANA
B. Anti-dsDNA
C. Anti-SM
D. Antiphospholipid antibody
A
High specificity for diagnosis of lupus
A. ANA
B. Anti-dsDNA
C. Anti-SM
D. Antiphospholipid antibody
B and C
important marker in lupus nephritis*
A. ANA
B. Anti-dsDNA
C. Anti-SM
D. Antiphospholipid antibody
B
Anti-SM AB binds to __ proteins that are attached to _______
SM, DNA
found in smaller % of patients
A. ANA
B. Anti-dsDNA
C. Anti-SM
D. Antiphospholipid antibody
C
increase clotting factors
A. ANA
B. Anti-dsDNA
C. Anti-SM
D. Antiphospholipid antibody
D
T or F:
in healthy patients each of the four key labs is typically negative
tru
what is the medication yasmin said ALL patients can use for lupus?
Hydroxychloroquine (every card after this it will just be HCQ)
HCQ MOA
antimalarial -> inhibit overactive immune cells
HCQ place in therapy
recommended for all patients with lupus
2 benefits for HCQ
reduce flares
help manage pain
dosing for HCQ
normal and max
fuck her for this shit but its 200-400 mg PO daily with max of 400
HCQ side effects (theres a lot but ill * the ones i think are most important)
- retinal toxicity (bulls eye maculopathy) *
- CNS effects
- QT prolongation*
- myopathy
- hypersensitivity reaction
- Hypoglycemia*
- G6PD deficiency***
G6PD deficiency is a(n) (X/Y) linked disorder that causes what?
x-linked and causes RBCs to prematurely break down
G6PD converts what to what?
NADP+ to NADPH
G6PD conversion is important for production of _________
glutathione
what does glutathione do?
antioxidant that gets rid of free radicals that damage blood cells
avoid giving in pt with G6PD deficiency:
A. NSAIDs
B. Cyclophosphamide
C. Prednisone
D. HCQ
D
4 baseline monitoring parameters for HCQ
CBC
LFTs
SCr
EKG - bc qt prolongation
1 periodic monitoring parameter for HCQ
Eye exam. 3 months after starting, yearly after that
NSAIDs MOA
inhibit COX 1 and COX 2 and decrease prostaglandin precursor
NSAIDs particularly helpful with what 4 things in lupus
fevers
serositis
myalgias
arthralgias
NSAIDs place in therapy for lupus
1st line for mild symptoms
ibuprofen dosing on slide
400-600 mg PO q6-8 hr
naproxen dosing from slide
500 mg PO BID
5 baseline monitoring parameters for NSAIDs
CBC
LFTs
SCr
BP
(also s/sx of fluid retention and bleeding duh)
Glucocorticoids MOA
inhibit B and T cell responses
3 benefits of glucocorticoids
anti-inflam
helpful during flares
variable dosage forms (PO, topical, IV)
Glucocorticoids place in therapy for lupus
adjunctive treatment if not responsive to NSAIDs/HCQ
T or F:
If a pt does not improve on HCQ and NSAIDs you can add on glucocorticoids no problem
true, can take all together
Mild/moderate disease oral glucocorticoid drug and strength
prednisone 5-30 mg/day *
severe disease oral glucocorticoid drug and strength
prednisone 1mg/kg/day
IV glucocorticoid drug and regimen *
methylprednisolone 500-1000 mg IV daily 3-6 days, then PO prednisone after (no timeline for that one shown on slide)
when are the topical GCs used in lupus?
cutaneous lupus (rash shit), ulcers, raynauds (do we actually do that for raynauds? seems like it wouldnt do anything)
Topical GCs use:
Fluocinolone valerate & hydrocortisone butyrate (face)
A. Low-potency
B. Mod-potency
C. High-potency
A
Topical GCs use:
Triamcinolone acetonide & betamethasone valerate (trunk and extremities)
A. Low-potency
B. Mod-potency
C. High-potency
B
topical GCs use:
Clobetasol (scalp sores and palms)
A. Low-potency
B. Mod-potency
C. High-potency
C
3 topical GC side effects (these are typically with long term use)
skin atrophy
rosacea
telangiectasis -> blood vessels more shallow
4 baseline monitoring parameters for GCs
BP
BMP
FLP
Bone mineral density
routine monitoring parameters for GCs:
BMP: every _ months
FLP: every _ months
Bone mineral density: _______
6
6
annually
4 immunosuppressants used in lupus
- Methotrexate (MTX)
- Azathioprine (AZA)
- Cyclophosphamide (CYC)
- Mycophenolate mofetil (MMF)
Immunosuppressants MOA
suppression of immune function from attacking healthy cells
Immunosuppressants place in therapy (2)
- adjunct to steroid therapy to lower the dose
- insufficient response to HCQ
MTX initial dose *
PO
5-15 mg once weekly
Mycophenolate mofetil initial dose *
PO
1-1.5g twice daily
Does not have a side effect/toxicity of malignancy
A. MTX
B. MMF
C. CYC
D. AZA
A *
BMS/Infection
A. MTX
B. MMF
C. CYC
D. AZA
all of them
Androgen insensitivity syndrome (AIS)
A. MTX
B. MMF
C. CYC
D. AZA
B
only one that is both IV and oral
A. MTX
B. MMF
C. CYC
D. AZA
C
Monitor TPMT deficiency
A. MTX
B. MMF
C. CYC
D. AZA
D
CYC initial dose
1-1.5mg/kg once daily (is this oral or IV?)
AZA initial dose
50 mg po qd
Do not give if TPMT deficient
A. MTX
B. MMF
C. CYC
D. AZA
D
3 biologics used in lupus
Belimumab
Rituximab
Anifrolumab
MOA of biologics in lupus
mabs that block B-cell mediated immunity
Biologics place in therapy for lupus (2)
- inadequate response to HCQ and immunosuppressants
- severe disease*
2 pearls for biologics (super hard)
no live vaccines 30 days prior to starting therapy or during
and
dont use more than one at same time (woah fr)
specific for lupus
A. Belimumab
B. Rituximab
C. Anifrolumab
A and C
belimumab initial dose (IV btw)
10mg/kg every 2 weeks for 3 doses
anifrolumab initial dose (IV)
300 mg every 4 weeks
side effect/toxicity of malignancy *
A. Belimumab
B. Rituximab
C. Anifrolumab
C
does not have infusion reactions listed in slides:
A. Belimumab
B. Rituximab
C. Anifrolumab
C
absolutely premedicate
A. Belimumab
B. Rituximab
C. Anifrolumab
B
Risk of Hep B reactivation
A. Belimumab
B. Rituximab
C. Anifrolumab
B
rituximab initial dose (IV)
1 g on days 0 and
15 or
375 mg/m2 once
weekly
for 4 doses
no idea wtf this is but its on the slides so idk someone correct me if its too fucked up
PML risk
A. Belimumab
B. Rituximab
C. Anifrolumab
B
CNI drugs (additional therapies)
tacroLIMUS
pimecroLIMUS
vocloSPORIN
3 non pharm things to help lupus
rest+exercise
smoking cessation
sun exposure + sunscreen
first lin cutaneous lupus
Topical agents
refractory cutaneous lupus
Higher dose GC
MTX
MMF
therapy for mild/mod lupus nephritis *
GC +/- another immunosuppressant (AZA, MMF, or CNI)
treatment for severe lupus nephritis
MMF (preferred) *
OR CYC +/- GC
could also consider triple therapy being:
Belimumab + MMF or CYC +/- GC
or
CNI + MMF +/- GC
wtf
review slide 61 with someone smart
this is a call for help
The best prognosis is when the patient achieves remission for ≥ _ months before pregnancy
6
avoid what kind of contraception for lupus
estrogen-containing
basically the only 3 drugs we want to use in pregnancy
HCQ
NSAIDs
GC
which drug is drug of choice in pregnancy
HCQ
when to d/c NSAIDs in pregnancy
at 20 weeks or later due to risk of premature closing of ductus arteriosus
T or F:
antiphospholipid syndrome is an autoimmune disorder
true
what two things can antiphospholipid syndrome cause?
blood clots
miscarriages
drug therapy for antiphospholipid syndrome prophylaxis with no prior fetal loss
aspirin 81 mg
drug therapy for antiphospholipid syndrome prophylaxis with prior fetal loss (does this mean a previous miscarriage?)
aspirin 81 mg +/- LMWH
therapy for acute thrombotic event/hx of thrombosis in antiphospholipid syndrome
LMWH (enox or dalte)
