Exam 2: Multiple Sclerosis Flashcards
MS definition
- Multiple - multiple areas of lost myelin (from myelin sheath, which wraps around the axon)
- Scleorosis - scarring
Autoimmune inflammatory disease affecting CNS
- Imapairs nerve abiity to send electrical impuse
- Inflammation and immune activity ( T and B lymphocytes, macrophages, destructie cytokines, Ab, and complement) → demyelination of axon
MS associated factors
- Vit D deficiency
- Smoking increases risk
- Infectious factors (measles, canine distemper, herpes, epstein-barr, an chlamydia can trigger
- Not being pregnant, somehow MS is less bitchy if youre pregnant
MS S/S
- Visual symptoms (blurred or double vision)
- Usnteady gait/balance issues
- Pain/paresthesias
- Emotional/cognitive disturbances
- Concentration issues
- Short term mempry loss
- Fatigue
- Sexual dysfunction
- Speech
- Swallong
- Abnormal sensations (tingling, numbesss)
- Senstiivity to heat
- Blader and bowel problems (freqency adn control)
- Charcot’s triad
- Dysarthria
- Difficult or unclear speach
- Plaques in brainstem interfere with conscious and unconsciousness movement
- Nystagmus
- Involuntary eye movement
- Plaques on nerves controlling eye movement
- If optic nerve → loss of vision
- Intention tremor
- Plaques unlong motor pathways
- Muscle weakness → ataxia and paralysis
- Dysarthria
What are the 4 types of MS
RRMS (relapsing remitting) - episodes with no increase in disability BETWEEN episodes, each episode just leaves pt a little worse off
SPMS (secondary progressive) - had a few episodes early on but is now just steadily worsening
PPMS (primary progressive) - no episodes, just steady worsening
PRMS (progressive-relapsing) - episodes with steady worsening in between
CIS
Cinically isolated syndrome - first episode of neurologic symptos lasting at least 24 hrs aused by inflmamtion and emyleination in onr or more sites in CNS, may not develop MS
MS DX
- Alternative Dx considered then exlcuded
- Pt must have at least 2 clinical exacerbations separted by timd and space as well as 2 distinct MRI lesions
- DCSF tap - looking for high level of Abs
- Visual evoked potential - measure response to visual stimuli
All of the following are common side effects of fumarate derivatives EXCEPT:
- nausea
- flushing
- diarrhea
- alopecia
Alopecia
Which of the following is not a fumarate derivative?
- Aubaigo
- Tecfidera
- Vulmerity
- Bafiertam
Aubagio
Which drug is approved for pseudobulbar affect disorder?
Neudexta (dextromethorphan/quinidine)
Which drug is approved for walking?
Ampyra (Dalfampridine)
to remember, think “amble”
Which S1P drug has a drug interactions with SSRIs, SNRIs, MAOis, and tyramine in its PI?
Ozonimod
Which 2C9 genotype requires dose adjustent with siponimod?
*1/ *3
*2/ *3
Which 2C9 genotype is contraindicated with siponimod?
*3/ *3
Which S1P drug requires genotyping
Siponimod
The first dose monitoring is to monitor for which of the following side effects of S1P drugs?
bradycardia, QTc prolongation, conduction abnormalities
Which S1P drug always requires at least 6 hour First dose monitoring?
Fingolimod
Which chemotherapeutic drug is given orally for 2 years, which 2 cycles/year?
Cladribine
Which chemotherapeutic drug is given as IV and has a cumulative lifetime dose of 100 mg/m2 due to cardiotoxicity?
Mitoxantrone
Which MS mAb is reserved for patients who have failed 2 or more disease modifying therapies due to its side effect profile which includes one-third of patients developing thyroid issues?
Alemtuzumab
Which MS mAb can be given at home by SubQ injection?
Ofatunumab
Which MS mAbs work on CD20?
OCrelizumab
Ofatunumab
Which MS mAb blocks migration of Leukocytes across the BBB
Natalizumab
What are the ABCR therapies and which does not cause depression or Flu-like symptoms, is synthetic, and is safest to use in a woman of child bearing potential?
Avonex
Betaseron
Copaxone
Rebif
What medication is effective for PPMS
Ocrelizumab (Ocrevus)
Which MS meds have live vaccine considerations?
Ofatunumab (Kesimpta) - give vaccine 4+ wks before and/or 2+ after
Cladribine (Mavenlad) - give vaccine 4+ wks before and/or 3 mo. after
Fingolimod (Gilenya) - give zoster 30 days before and no live accines while on med
Mayzent/Siponimod give vaccine 4+ wks before and/or 4+ after
Zeposia/Ozonimod - give vaccine 1 mo before
Pseudobulbar affect definition
uncontrollable crying or laughig even if they are not feeling that emotion - in pts with ALS, MS, AD, PD, stroke, TBI
Dalfampridine (Ampyra) CI
CI in pts with mdoerate or severe renal impairment, hx of seizure
Dalfampridine (Ampyra) MOA
broad specturm K channel blocker → incrase conduction of action potentials in demyelinated axonx
Dalfampridine (Ampyra) dose
10mg BID (do not crush, chew or dissolve)
Dalfampridine (Ampyra) AE
asthenia
balance, dizziness
HA
insomnia
paresthesia
nasopharyngitis
pharyngolarneal pain
constipation
dyspepsia
nausea
back pain
UTI
Nuedexta (dextrometorphan HBr and Quindine sulfate) MOA
- Dextrometorphan: may inhibit glutamatergic neurotransmitter vai action at vairety of lcoations including NMDA receptor and sigma-1 receptors
- may play a role in behavior
- Quinidine: helps with blocking metabolism of dextrometorphan (CYP2D6) → increase serum [ ]
Nuedexta (dextrometorphan HBr and Quindine sulfate) dose
Dose: 1C (20/10mg) PO QD 7D then titrate up to 1C BID
the quinidine dose is 1-3% of the dose needed for arrhymthias
Meds for general s/s of MS
- baclofen
- dantrolene
- diazepam, clonazepam
- tizanidine
- gabapentin, tiagabine, pregabalin
- botox
- cannabinoids (insufficient data for or against)
Meds for cogntiive s/s in MS
- amantadine
- SSRI, SNRI
- modafanil
- methylphenidate
- dextroamphetamine
Meds for sensory s/s in MS
- CBZ, OxCBZ
- phenytoin
- TCAs
- gabapentin, pregabalin
- lamotrigine
- duloxetine
Meds for bladder treatment in MS
- propantehline
- oxybutinin and co.
- mirabegron
- dicyclomine
- desmopressin acetate
- TCAs
- prazosin
- botox
- catheter (not a med)
Monomethyl fumerate (Bafiertam) AE
flushing (asa325mg 30min prior to reduce)
transient increase in LFTS
transient eosinophilia
lymphopenia (consdier swithcing if lymphocytes <500 for 6mo)
PML
urinalysis
Monomethyl fumerate (Bafiertam) dosing in MS and storage
start 95mg BID 7D then 190mg BID (if not tolerated, trial lower dose for 4 weeks before increasing again, if still not tolerated, consider d/c)
store unopened bottle in refrigerator and opened bottle at room temp for up to 3 months
Monomethyl fumerate (Bafiertam) MOA
bioequiv to Tecfidera but lower dose → potential for les GI AE
Induce t helper 2-like cytokines (IL 4, 5 10) causing →
- apoptosis in active t cells
- downregulation of adhesion molecules → reduced migration of lymphocytes
Which forms of MS can monomethyl fumerate (Bafiertam) be used for?
relpasing forms (CIS, RRMS, active SPMS)
Diroximel fumerate (Vulmerity) dosing in MS and admin
start 231mg BID 7d then 462mg BID (if not tolerated, trial lower dose for 4 weeks before increasing again, if still not tolerated, consider d/c)
do NOT ake with a high fat (>30g) or high calorie meal (>700 cal) d/t decreased peak [ ]; avoid EtOH at time of admin
Diroximel fumerate (Vulmerity) AE
flushing (asa325mg 30min prior to reduce)
transient increase in LFTS
transient eosinophilia
lymphopenia (consdier swithcing if lymphocytes <500 for 6mo)
PML
urinalysis
Diroximel fumerate (Vulmerity) MOA
(like Tecfidera) - but less GI irritation
Induce t helper 2-like cytokines (IL 4, 5 10) causing →
- apoptosis in active t cells
- downregulation of adhesion molecules → reduced migration of lymphocytes
Which form of MS is Diroximel fumerate (Vulmerity) used for?
relpasing forms (CIS, RRMS, active SPMS)
Dimehtyl fumarate (Tecfidera) monitoring
liver test prior to treatment and as clincially idicated after start
CBC needed 6 months before starting and Q3mo after
Dimehtyl fumarate (Tecfidera) AE
GI
flushing (asa325mg 30min prior to reduce)
transient increase in LFTS
transient eosinophilia
lymphopenia (consdier swithcing if lymphocytes <500 for 6mo)
PML
urinalysis
Dimehtyl fumarate (Tecfidera) dosing in MS and admin
DR tabs: start 120mg PO BID 7D then 240mg PO BID
(though admin with high fat, high protein food - yogurt, peanut butter) may decrease incidence of flushing and GI
Dimehtyl fumarate (Tecfidera) MOA
Induce t helper 2-like cytokines (IL 4, 5 10) causing →
- apoptosis in active t cells
- downregulation of adhesion molecules → reduced migration of lymphocytes
Whcih forms of MS is dimehtyl fumarate (Tecfidera) used for?
relpasing forms (CIS, RRMS, active SPMS)
Teriflunomide (Aubagio) monitoring
- may decrease WBC - CBC within 6 months before starting
- liver and bili tests within 6 months before and every month after start for at least 6 months
- screen for latent TB
Teriflunomide (Aubagio) DDI
may increase exposure to drugs metabolised by CYP2C8, OAT3, BCRP, and OAT1B1/B3, and ethinylestradiol and levonortestrol
- cholestyramine increases eliination (lower [ ] by 98% has clinical use)
- activated charcoal increase elimination
- may decrease INR in warfarin ps
- crestor should NOT exceed 10mg
Teriflunomide (Aubagio) AE and BBW
HA
nasopharyngitis
URI, UTI
alopecia
sensory disturnace
nasuea, diarrhea
insomnia
fatigue
incrased LFTs
back pain, arhtralgia, limb pain
parathessias
BBW: hepatotoxicity and teratogenicity
Teriflunomide (Aubagio) preggers consideration
NOT FOR PREGGERS OR BREASTFEEDING (use cholestyramine and charcoal to washout quickly,if not used may be in system for up to 2 years after d/c)
Teriflunomide (Aubagio) MOA
Blocks pyrimidine synthesis in rapidly dividing cells, inhibit proein tyrosine-kinase and COX2 actiivty, and decreases ability of antigen presenting cells to activate Tcells
selectively produces a cytostatic effect in proliferating T and B lymphocutes in periphery → reduces B lymphocye proliferation
Which form sof MS is Teriflunomide (Aubagio) used in?
Relapsing forms of (RRMS and SPMS)
Zeposia/Ozonimod monitoring
- CBC at baseline and at 6 moths
- bilirubin and liver enzymes at baseline at at 6mo
- ECG baseline, HR, BP, s/s of bradycardia
- eye tests
Zeposia/Ozonimod ddi
- BCRP
- CYP2C8
- CYP3A4 (minor)
Zeposia/Ozonimod CI
CI: heart problems, severe unobstrcted sleep apmea and MAOI
Zeposia/Ozonimod AE
AV block
bradycardia
hepatotoxicity
HTN and orthostatic hypotension
ifection; URI; UTI
lymphpenia
macular edema
neurotoxicity
PML
respiratory
CV; QT prolongation
Zeposia/Ozonimod preggers consideration
Use effectve contraception during and 3 months after
Zeposia/Ozonimod dosing in MS
start 0.23mg QD 4D then 0.46mg 2D then 0.92mg QD
- if dose missed during tiration, restart
Zeposia/Ozonimod MOA
high affinity for S1P receptors 1 and 5 → block lymphocytes’ ability to emerge form lymph nodes → deccrase lymphocytes in CNS
Mayzent/Siponimod monitoring
- CBC at baseline, and within 6 months
- eye exam
- ECG prior to start
- baseline LFTs and within 6 monthsz
If pt has
- sinus bradycardia <55bpm
- Mobitz type 1 first or second degree AV block
- hx MI
- HF
additional monitoring for the 6hrs following dose admin
- monitor pt 6hrs post 1st dose for bradycardia (HR and BP)
- continue observing if bpm <45 or if HR is still at lowest after 6hrs
Mayzent/Siponimod AE
infection
PML
macular edema
bradycardia
AV conduction delay
QTc prolongation
CV disease
respiratory effects
hepatic effects
HTN
neurotoxicity
malignancy
HA
fallin
Mayzent/Siponimod CI
- MI in past 6 months
- unstable angina
- stroke, TIA
- HF requiring hospilazing or calss III or IV HF
- Mobitz type 2 second ro third degree AV block
- sick sinus syndrome (unless pacemaker)
Mayzent/Siponimod preggers consideration
use effective contraception during and for 10 days after last dose
Mayzent/Siponimod dosing in MS and storage
available as 0.25 or 2mg tabs
store unopened in fridge and opned in room temp for <3 mo.
CYP2C9 genotype 1/1, 1/2, or 2/2
- start 0.25mg QD 2D, then 0.5mg 1D, then 0.75mg 1D, then 1.25mg 1D, then 2mg QD
CYP2C9 genotype 1/3 or 2/3
- start 0.25mg QD 2D, then 0.5mg 1D, then 0.75mg 1D, then 1mg QD
CYP2C9 genotype 3/3
- contraindicated
if dosed msised for more than 24hrs during titration, start over
if 4+ consecutive days missed during maintenance, restart titration
Mayzent/Siponimod MOA
S1P receptor moduator, binds to receptors 1 and 5 → block lymphocytes’ ability to emerge from lymph nodes 0> decrease amount of lymphocytes in CNS → decrease central inflammation
Which forms of MS is Mayzent/Siponimod used for?
relapsing forms of MS (CIS, RRMS, and active SPMS)
Fingolimod (Gilenya) AE
prolonged qTC → DDI and CI in pts wtih hx of cardio disease
HA
lymphopenia, leukopenia
URI
macular edema (get baseline eye exam and 3-4 months after)
increase in bp, HTN
elevated LFTs
pain
diarrhea
decreased HR
Fingolimod (Gilenya) monitoring
- ECG before initaing
- monitor pt 6hrs post 1st dose for bradycardia (HR and BP)
- continue observing if bpm <45 or if HR is still at lowest after 6hrs
- monitor overnight if pt at incrased risk for torsades
- monitor 1st dose again
- if pt misses 1 day in first 2 weeks
- 7 days in 34d and 4th weeks
- 14 days after 1 month
- Eye exam at base line and 3-4 months after starting
Fingolimod (Gilenya) dosing in MS
0.5 mg QD
no food effect, no adjustment for renal, hepatic, age, gender or race
Fingolimod (Gilenya) MOA
acts on S1P1 and S1P 3-5 on the surface of lymphocytes → deplete Cd4 and CD8 in baseline and inhibit lymphocyte release from lyphatic organs
Which forms of MS is Fingolimod (Gilenya) used in
relapsing forms of MS (RRMS and active SPMS) in pts 10+ y/o
Cladribine (Mavenlad) monitoring
- Liver function
- CBC at start of each treatment and 2 and 6 months after each yearly course
Cladribine (Mavenlad) DDI
DDI
- BBCRP/ABCG2
- PGP/ABCB1
- immunosuppresants
- decreased effectiveness of contraceptives
Cladribine (Mavenlad) AE
bone marrow suppression
infecetion, URI
PML
graft versus host disease; hypersensitivity reaction
hepatotoxic
cardiotoxic
CNS (HA)
GI
lymphocytopenia
thrombocytopenia
Cladribine (Mavenlad) CI
CI in pts with current malignancy or in preggers or in breastfeeding
- effective contraception during dosing and for 6 months after last dose
Cladribine (Mavenlad) MOA
- chemo agent
Purine nucleoside anaglue → incorporated into DNA → breakage of DNA strand → shutdown of DNA syntesis and repair → may have cytotoxic effects on B and T lymphocytes
Also depletes ATP
Cell-cycle non-speific
Whihc forms of MS is Cladribine (Mavenlad) used in
for relapsing forms of MS (RRMS and active SPMS) in adults who have had inadquate response or are intolerant to other therapies
Mitoxantrone (Novantrone) AE
cardiotoxicity
bone marrow suprresion, get CBC before each infusion
stomatitits, esophagitis, oral ulceration
N/V
alopecia
HA
fatigue
hepatic dysfunction
Mitoxantrone (Novantrone) preggers consideration
Preggers D; significant [ ] can also remain in breast milk for 28 days
Mitoxantrone (Novantrone) dosing in MS
IV Q3mo. ; each dose is 12mg/m^2
- life-time dose: of 100mg/m^2 (d/t cardio tox)
Mitoxantrone (Novantrone) MOA
chemo agent
Intercalates with DNA strands → breaks in DNA → inhibit DNA repair through topoisomerase II
Affects rapidly dividing cells (chemo agent) with secndoary effects on immune system
- antigen presentation
- pro-inflammatory cytokine expresion
- decreased leukocyte migration
Which forms fo MS is Mitoxantrone (Novantrone) use din
SPMS, PRMS, or worsening or RRMS to reduce neurologic disability and/or frequency of relapse
- NOT indicated for PPMS, really just reserved for rapdily-advacning refractory MS
Ofatunumab (Kesimpta) monitoring
- LFTs
- HepB screen (d/t contraindication)
- monitor Ig levvels
Ofatunumab (Kesimpta) AE
URI
UTI
SQ= systemic and local inj reactions
PML
HA
increased LFTS
Ofatunumab (Kesimpta) preggers consideration
Females of reproductive potential should use effective contraception during adn for 6 months after alst dose
Ofatunumab (Kesimpta) dosing in MS, storage, and amdin
Sq 20mg QW for 3 weeks, then maintenance of 20mg SQ Qmo.
- stored in fridge, allow to warm up (15-30min) before admin (can be given at home)
- SQ in abdomen, thigh or uter opper arm in unmarred scin
Ofatunumab (Kesimpta) MOA
Binds to extracellular loops of CD20 → potent complement-dependent cell lysis and Ab-dependneted cell-ediated toxicity in cells that overexpress CD20
Ocrelizumab (OCrevus) monitoring
LFTs
Ocrelizumab (OCrevus) AE
infusion reaction
- premeidcate with steroids (methylprednisolone 100mg IV 30min prior)
- antipyretic (APAP)
- antihistamines (diphenhdramine 30-60mi prior)
UTI
URI
HA
nausea
incrased LFTS
Ocrelizumab (OCrevus) CI
HBV infection → screen befores starting
Ocrelizumab (OCrevus) dosing in MS
start with 300mg IV, then 14D later another 300mg
then 6 mo after first dose, 600mg; and 600mg Q6mo therafeter
Ocrelizumab (OCrevus) MOA
humanized mAb
binds to CD20 n surface of B cells and deplete them from circulation
may play a role in immune system mediataed amage to brain and spinal cord tissues
Which forms of MS is Ocrelizumab (OCrevus) use din
- PPMS and relapsing forms of MS (CIS, RRMS, and active SPMS)
- reduces relapse rates, disability progression and disease acitivity in pts with RRMs and SPMS
- reduces disability progression, volume of brain lesions, and whole brain volume loss in PPMS
Alemtuzuma (Lemtrada) AE
Development of autoimmune thyroid disorders (including graves)
rash
HA
pyrexia
fatigue
pruritis, uritcaria
N/V, diarrhea, dyspepsia
neurologic problems, paresthesia, dizziness
chills
insomnia
dyspnea, nasopharyngitis
musculoskeletal pain
flushing
infections (UTI, URI, sinusitis, fungal infection)
incrased LFTS → LFT monitoring
Alemtuzuma (Lemtrada) bbw
- automimmune condiitions (including immune thrombocytopenia)
- infusion rectoin increased risk of malignancy
Alemtuzuma (Lemtrada) monitoring
- urinalysis
- TSH at baseline and Q3mo until 2 years afer last infusion
- ECG prior to treatment
- annual HPV
- baseline adn annual skin exams
- s/s of PML
- LFT monitoring
Observe pt 2 hrs after infusion
Alemtuzuma (Lemtrada) dosing in MS
12mg IV over 4 hrs for 5 days, then a 3 day course at month 12
can be treated for another 3 days after 12 months
admin antiviral ppx beginning on the first day of treatment adn continue for at least 2 months after completion and unti CD4 count is >200
premedicate with corticosteroids (1000mg methylprednisolone or equiv)
- give immediately proir for first 3 days of treatment
- can consider antihistamins or antipyretics
Alemtuzuma (Lemtrada) MOA
humanzied mAb
targets CD52 on T nd B lymphocytes, NK cells, macrophages, and monocytes → long term reduction of ciruclating T cells
Which forms of MS is Alemtuzuma (Lemtrada) use din?
relapsing forms of MS (RRMS and SPMS) ;
though generally reservved for pts with inadequate response to 2 or mroe meds d/t safety profile
Natalizumab (Tysabri) monitoring
LFT monitoring
Natalizumab (Tysabri) AE
infusion reactio
hypersensiitivy reaction
respiratory tract infectio
UTI
depression
HA
fatigue
diarrhea
cholelithases
arthralgia
PML
incrased LFTS
Natalizumab (Tysabri) dosing in MS
300mg IV Q4W
Natalizumab (Tysabri) MOA
antagonizes alpha 4-itegrin of the adhesion molecule ver late activating antigen (VLA)-4 on leukocyes → prevents transmigration of leukocytes across the andothelium into inflamed parenchymal tissue
WHich forms of MS is Natalizumab (Tysabri) used in
relapsing forms (CIS, RRM, active SPMS)
Copaxone, Glatopa AE
Injection site reactions (including indurations, masses, and welts)
transient flusing
vasodilation (feels like a heart attack)
constriction of throat
asthenia
N/V
pain
arthralgia
anx
palpitations
dyspnea
Copaxone, Glatopa dosing in MS
20mg SQ QD or 40mg TIW
Copaxone, Glatopa MOA
glatiraer acetate
though to be related to alteration of Tcell activation and differentiation
Which forms of MS is Copaxone, Glatopa use in
relapsing forms (CIS, RRM, active SPMS)
interferon beta-1a AE
flu-like symptoms → pre and psot medciate y a day with ibuprofen or APAP, dissipates with continued use; generally worse in females and those with low TBW
inj site reaction
depression
myalgia
arthralgia
asthemnia
malaise
diaphoresis
myastehnia
Betaseron, Etaviab MOA
Inteferon beta-1a
May augment suppressor T-cell function
May decrease macrophage activating effect
May decrease interferon gamma secretion by activating lymphocytes
May down-regulate expression of MHC gene production on atigen preseting cells
May suppress T cell proliferation adn decrease BBB permeabiity
Which forms of MS is Betaseron (Extavia) used in
relapsing forms (CIS, RRM, active SPMS)
Rebif MOA
Inteferon beta-1a:
May augment suppressor T-cell function
May decrease macrophage activating effect
May decrease interferon gamma secretion by activating lymphocytes
May down-regulate expression of MHC gene production on atigen preseting cells
May suppress T cell proliferation adn decrease BBB permeabiity
Which forms of MS is Rebif use din
relapsing forms (CIS, RRM, active SPMS)
Plegridy MOA
Inteferon beta-1a: pegylated form → maintain effects longer in body
May augment suppressor T-cell function
May decrease macrophage activating effect
May decrease interferon gamma secretion by activating lymphocytes
May down-regulate expression of MHC gene production on atigen preseting cells
May suppress T cell proliferation adn decrease BBB permeabiity
Which forms of MS is Plegridy used in
relapsing forms (CIS, RRM, active SPMS)
Avonex MOA
Inteferon beta-1a:
May augment suppressor T-cell function
May decrease macrophage activating effect
May decrease interferon gamma secretion by activating lymphocytes
May down-regulate expression of MHC gene production on atigen preseting cells
May suppress T cell proliferation adn decrease BBB permeabiity
Whch form of MS is Avonex use di
relapsing forms (CIS, RRM, active SPMS)
Corticotropin Acthar gel dosing in MS
IM or SQ 80-120 U/day for 2-3 weeks
Corticotropin Acthar mOA
Stimuate adrenal cortex to secete adrenal steroids (including cortissol), weakly androgenic substances, and aldosterone
What is Corticotropin Acthar used for in MS
acute exacerbation
Corticosteroid AE
insomnia
mood changes (irratibility)
GI upset (give H2 bblocker or PPI)
Corticosteroid dosing in MS
Methylprednsoline 1gm IV QD 3-5D
may be followed by prednosone taper (60mg QD 7D, then 60mg QOD 7D, then 40mg QOD 7D, then 20mg QOD 7D)
What are corticosteroids used for in MS
Acute exaceration
corticosteroid MOA
Decreases nflammation by preventing migration of polymorphonuclear leukcytes and reversal of capillary permeability
