Exam 4 Drugs Flashcards
1
Q
ASA treatment
A
-Sulfasalazine
-Mesalamine
2
Q
Immunosuppressives for IBD
A
-Azathiopurine
-Mercaptopurine
-Cyclosporine
-Methotrexate
3
Q
TNF-alpha inhibitors
A
-Etanercept
-Infliximab
-Adalimumab
-Certolizumab
-Golimumab
4
Q
Anti-integrins
A
-Natalizumab
-Vedolizumab
5
Q
Anti-interleukins
A
-Ustekinumab
-Risankizumab-rzaa
-Mirikizumab-mrkz
6
Q
JAK inhibitors
A
-Tofacitinib
-Upadacitinib
7
Q
S1P receptor modulators
A
-Ozanimod
-Estrasimod
8
Q
TNF inhibitors class ADRs
A
-Increased risk of serious infections
-Injection site reactions and infusion related reactions
-Risk of malignancy
-Hepatosplenic T-cell lymphoma
-Risk of demyelinating disease
-May exacerbate CHF
-Hepatitis B reactivation
-No concurrent live vaccination administration
-Headaches and rash
9
Q
TNF inhibitors class monitoring
A
-CXR, PPD every 8-12 weeks
-Signs and symptoms of infection every 8-12 weeks
-UA every 8-12 weeks
-CBC every 8-12 weeks
-SCr, lytes every 8-12 weeks
-LFTs every 8-12 weeks
-Hep B, C every 8-12 weeks
10
Q
Infliximab indication
A
UC and CD
11
Q
Infliximab monitoring
A
-S/S of infection
-Vitals
-Infusion reactions
-TDM
12
Q
Adalimumab indication
A
UC and CD
13
Q
Golimumab indication
A
UC
14
Q
Certolizumab indication
A
CD
15
Q
Natalizumab indication
A
CD
16
Q
Natalizumab adverse effects
A
Associated with progressive multifocal leukoencephalopathy
17
Q
Vedolizumab indication
A
UC and CD
18
Q
Ustekinumab indication
A
CD and UC
19
Q
Ustekinumab ADRs
A
-Similar to other biologics
-Hypersensitivity possible (including anaphylaxis and angioedema)
-ADAs
-Rapidly developing cutaneous cell carcinoma in patients with risk factors
-Possible neurotoxicity (RPLS and PRES)
20
Q
Ustekinumab monitoring
A
-CXR
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - check for signs and symptoms
-Skin annually
21
Q
Risankizumab-rzaa indication
A
CD and UC
22
Q
Risankizumab-rzaa adverse effects
A
-Headache
-Nasopharyngitis
-Arthralgia
-Abdominal pain
-Anemia
-Nausea
-Infections/latent infections (TB)
-Hypersensitivity possible
-ADAs
-Potential hepatotoxicity
-Increase in lipids
23
Q
Risankizumab-rzaa monitoring
A
-CXR, PPD
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - monitor signs and symptoms
24
Q
Mirikizumab-mrkz indication
A
UC
25
Mirikizumab-mrkz adverse effects
-Headache
-Arthralgia
-Rash
-Injection site reaction
-Infections/latent infections (TB)
-Upper respiratory tract infections
-Hypersensitivity possible
ADAs
-Potential hepatotoxicity (increase in LFTs)
26
Mirikizumab-mrkz monitoring
-CXR, PPD
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - monitor for signs and symptoms
27
What does it mean when biologics have sub-therapeutic drug levels and detectable ADAs?
Change to alternate drug within the same class +/- immunomodulator
28
What does it mean when biologics have sub-therapeutic drug levels and undetectable ADAs?
Dose escalate
29
What does it mean when biologics have therapeutic drug levels and detectable ADAs?
False positive or mechanistic failure so repeat test. If results consistent then switch to out of class biologic agent
30
What does it mean when biologics have therapeutic drug levels and undetectable ADAs?
Switch to out of class biologic agent
31
Tofacitinib indication
UC patients who have had an inadequate response or who are intolerant to TNF blockers
32
Tofacitinib adverse drug reactions
-Diarrhea
-Elevated cholesterol
-Headache
-Herpes zoster
-Increased creatine phosphokinase
-Nasopharyngitis
-Rash
-URI
-Malignancy
-Serious infection
-Neutropenia
-Hypersensitivity
33
Tofacitinib black box warning
-Increase mortality in RA patients 50 years and older with at least one CV risk factor
-Thrombosis - increased risk in RA patients 50 years and older with at least one CV risk factor
34
JAK inhibitor monitoring
-CXR, PPD
-Hep B, C
-ANC every 3 months
-CBC every 1-2 months then every 3 months
-Lipids 1-2 months after start then every 3 month
-LFTs 1-2 months after start then every 3 months
-Infection - monitor for signs and symptoms
-Skin exam periodically
35
Updacitinib indication
UC and CD
36
Updacitinbib black box warning
-Increase mortality in RA patients 50 years and older with at least one CV risk factor
-Thrombosis - increased risk in RA patients 50 years and older with at least one CV risk factor
37
Updacitinib adverse effects
-Increased risk of serious infection
-Upper respiratory tract infection
-Acne
-Increased creatine phosphokinase
-Elevated cholesterol
-Headache
-Herpes zoster
-Malignancy
-Increase in LFTs
-Anemia
-Neutropenia
-Lymphopenia
-Hypersensitivity
-Potentially teratogenic, excreted in breast milk
38
Ozanimod indication
UC
39
S1P contraindications
-Any major cardiac event in the last 6 months
-With Mobitz type 2 second or 3rd degree AV block, sick sinus syndrome, or SA block unless patient has functioning pacemaker
-With severe untreated sleep apnea
-Taking MOA inhibitor
40
Ozanimod adverse drug reactions
-Potential risk of infections
-Bradycardia/AV conduction delays
-Liver injury/elevated transaminases
-Moderate increase in systolic BP
-Respiratory effects - dose dependent reductions in FEV1
-Macular edema
-RPLS/PRES
41
Ozanimod drug interactions
-Adrenergic and serotonergic drugs
-Combination beta blocker and calcium channel blocker
-Foods high in tyramine
-MAO inhibitors - contraindication (active metabolite inhibits MAO-B)
42
S1P monitoring
-CXR, PPD
-Hep B, C
-CBC periodically
-LFTs periodically
-Infection - monitor for s/s
-BP each visit
-Spirometry if clinically indicated
-ECG
-Optho - regular exams
43
Estrasimod indication
UC
44
Estrasimod adverse drug reactions
-Potential risk of infections
-Risk of progressive multifocal leukoencephalopathy
-Bradycardia/AV conduction delays
-Liver injury/elevated transaminases
-Moderate increase in systolic BP
-Macular edema
-RPLS/PRES
-Respiratory effects
45
Which dosage form is best for treating left-sided disease?
Enema
46
Which dosage form is best for treating proctitis?
Suppositories
47
Which dosage form is best for treating pancolitis?
Requires systemic treatment
48
How to treat distal mild-moderate UC
-Sulfasalazine
-Mesalamine
49
How to treat extensive mild-moderate UC
-Mesalamine
-Budesonide
50
How to treat moderate-severe UC
-Budesonide
-Prednisone
-Treatment naive: prednisone + infliximab or vedolizumab +/- azathioprine
Previous infliximab exposure: ustekinumab to tofacitinib
51
Methotrexate dosing for RA
-2.5mg tablets
-7.5mg per week Po or IM (up to 15-20mg - weekly dose can be taken in one day)
-Onset: 1-2 months
52
Methotrexate contraindications
-Pregnancy
-Chronic liver disease
-Immunodeficiency
-Pre-existing blood dyscrasias
-Chronic liver disease
-Pleural/peritoneal effusions
-Leukopenia/thrombocytopenia
-CrCl < 40ml/min
53
Leflunomide mechanism of action
-Inhibit de novo biosynthesis of pyrimidines
-Interferes with tyrosine kinase activity
-Inhibit cell cycle progression
54
Leflunomide adverse effects
-Diarrhea
-Rash
-Alopecia
-Increased LFTs
-Teratogenicity
55
Leflunomide monitoring
-CBC
-SCr
-LFT
56
sulfasalazine mechanism of action
Inhibits IL-1
57
Sulfasalazine adverse effects
-N/V/D
-Anorexia
-Rash
-Urticaria
-Photosensitivity
-Leukopenia
-Thrombocytopenia
-Rare: hemolytic and aplastic anemia
-Caution for allergy
58
Sulfasalazine monitoring
-CBC
-SCr
-LFT
59
Hydroxychloroquine mechanism of action
Modification of cytokine infiltration in joint
60
Hydroxychloroquine adverse effects
-Retinal toxicity
-N/V/D
-Increase skin pigment
-Rash
-Alopecia
-Deficiency in G6PD increases free radical concentration in blood
61
Hydroxychloroquine monitoring
-Vision exam
-CBC
-LFTs
-SCr
-EKG
62
Etanercept mechanism of action
-Dimeric protein with two soluble TNF receptors fused to the IgG1 molecule
-Binds to and inhibits TNF
-Binding occurs before the cytokine can interact with cell-surface TNF receptors would produce an inflammatory response
63
Adalimumab indications RA
-Patients who have inadequate response to one or more DMARDS
-Can be used alone OR in combo
64
Golimumab indications RA
-Moderate to severe RA
-Used in combo with MTX
65
Golimumab monitoring
-CBC with PLT
-LFTs
66
Certolizumab indications RA
-RA patients with moderate to severe disease
-Can be used alone or in combo with non-BRM DMARDs
67
Anakinra indication RA
-Moderate to severe RA in patients who have failed one or more DMARDs
-Can use alone or in combo
68
Anakinra mechanism of action
-Recombinant, non-glycosylated version of the human IL-1 receptor antagonist
-Selectively blocks IL-1 binding to the IL-1 receptor
69
Anakinra adverse effects
-Injection site reactions
-Headache
-N/V
-Flu-like symptoms
-Hypersensitivity to e. coli-derived proteins
-Increased risk of serious infections
-Decreased neutrophils
70
Anakinra monitoring
Neutrophil count
71
Abatacept indication RA
-Moderate to severe RA
-If had inadequate response to one or more DMARDs
-Monotherapy or in combination with DMARD inhibitors or IL-1 antagonists
72
Abatacept mechanism of action
-Selective co-stimulation modulator
-Inhibits t-cell activation
73
Abatacept adverse effects
-Headache
-Nausea
-Upper respiratory infection
-Nasopharyngitis
-Infusion reactions
-Serious infection
-Malignancy
74
IL-6 receptor inhibitors
-Tocilizumab
-Sarilumab
75
IL-6 receptor inhibitor indication RA
-Moderate to severe RA after inadequate response to on or more DMARDs
-Alone or in combo with methotrexate or another DMARD
76
IL-6 receptor inhibitor mechanism of action
Binds to soluble and membrane-bound IL-6 receptors
77
IL-6 inhibitor warnings
-Black box warning: serious infections
-Contraindicated in patients with liver toxicity, thrombocytopenia, and neutropenia
78
IL-6 inhibitor adverse effects
-Serious infection
-Liver toxicity
-Thrombocytopenia
-Neutropenia
-Lipid abnormalities
-Intestinal perforations
-Infusion reactions
79
IL-6 inhibitor monitoring
-Neutrophil count at 4-8 weeks then every 3 months
-Platelet count at 4-8 weeks then every 3 months
-LFTs at 4-8 weeks then every 3 months
-Lipid profile after 4-8 weeks then every 6 months
80
Rituximab indication RA
-For moderate to severe RA
-In those with inadequate response to TNF antagonists
-In combination with methotrexate
81
Rituximab mechanism of action
Binds specifically to antigen CD20
82
Rituximab adverse effects
-Tumor lysis syndrome
-Mucocutaneous reactions
-Viral infection
-Hypersensitivity
-Renal toxicity
-Bowel obstruction
-Hepatitis B reactivation
-Cardiac arrhythmias
83
Rituximab monitoring
-CBC with platelet
-Serum creatinine
-Vital signs (during infusions)
84
JAK inhibitor indication RA
-Moderate to severe RA after inadequate response to TNF
-Alone or in combination with MTX or another DMARD
-Not in combination with BRM, azathioprine, or cyclosporine
85
How to reverse toxic metabolites from acetaminophen overdose?
N-acetylcysteine +/- activated charcoal
86
What are toxic doses of acetaminophen?
8 or more grams of acetaminophen
87
N-acetylcysteine indication
Based on concentration of acetaminophen (4 hours or more after ingestion) and timing since ingestion
88
Non-pharmacologic management of ascites
-Sodium restriction (less than 2g/day)
-Assessment for liver transplant
89
First-line treatment for ascites management
Aldosterone antagonist (spironolactone) + loop diuretic (furosemide)
90
Second-line treatment for ascites management
-Paracentesis
-TIPS
91
What do you want to avoid in patients with cirrhosis?
NSAIDs
92
Ratio of spironolactone to furosemide
100:40
93
Side effects of spironolactone
-Acute kidney injury
-Increased potassium
-Gynecomastia
94
Side effects of loop diuretics
-Acute kidney injury
-Decreased potassium
95
Monitoring of diuretics for ascites
-Signs and symptoms of ascites
-SCr
-K+
96
When to give albumin after performing a paracentesis
If >5L removed
97
Albumin dosing for replacement after paracentesis
25% albumin 6-8g per liter removed
98
Risk factors for variceal bleeding
-Varices size (larger more likely to rupture)
-Cirrhosis severity (Child Pugh)
-Red color markings noted on endoscopy
-Active alcohol use
99
Primary prophylaxis of variceal bleeding
-Nadolol
-Propranolol
-Carvedilol
-EVL
100
Side effects of beta blockers
-Drowsiness of insomnia
-Bradycardia
-Hypotension
101
Beta blockers monitoring
-HR: 55-60 bpm
-BP: SBP > 90 mmHg
-Signs/symptoms of VH
102
Treatment of variceal bleeding
-Blood transfusions
-Octreotide (somatostatin analog which is a vasoconstrictor)
-Antibiotic prophylaxis
-EVL
-PPIs not recommended
103
Octreotide duration
-2-5 days
-In practice, frequently stopped 24 hours after successful EVL
104
Octreotide side effects
-N/V
-HTN
-Bradycardia
-Hyperglycemia
105
Octreotide monitoring
-Signs/symptoms
-BP
-HR
-BG
106
Goal time frame to do EVL
12 hours upon presentation
107
Primary antibiotic prophylaxis
Ceftriaxone max 7 days
108
Ceftriaxone side effects
Diarrhea
109
Ceftriaxone monitoring
Signs and symptoms of infection
110
Contraindicated in variceal bleeding
Vitamin K
111
Secondary prophylaxis for varices
-EVL every 1-4 weeks
-NSBBs indefinitely until decompensated
112
SBP clinical presentation
-Fever
-Abdominal pain/tenderness
-Leukocytosis
-Encephalopathy
113
SBP treatment
-Ceftriaxone for 5-7 days
-Albumin
114
Albumin dosing for SBP
-Day 1: 1.5 g/kg x1
-Day 3: 1 g/kg x1
115
SBP secondary prophylaxis
-Bactrim
-Ciprofloxacin
-Avoid PPIs
116
Bactrim side effects
-Acute kidney injury
-Photosensitivity
-Hyperkalemia
-Hyponatremia
-Stevens-Johnson syndrome
-Agranulocytosis
117
Bactrim monitoring
-SCr
-Electrolytes
-CBC
118
Ciprofloxacin side effects
-Antibiotic resistance
-Musculoskeletal effects
-QTc prolongation
-Rash
-Altered mental status
119
Ciprofloxacin monitoring
-Mental status
-CBC
-Renal function
120
SBP secondary prophylaxis duration
Indefinitely
121
Stroke non-modifiable risk factors
-Age
-Family history
-Females
-Race
-Low birth weight
-Sickle cell disease
122
Stroke modifiable risk factors
-Cardiovascular diseases
-Diabetes
-Hyperlipidemia
-Hypertension
-Illicit drug/alcohol abuse
-Obesity/physical inactivity
-Cigarette smoking
123
Clinical presentation of stroke
-Dysphasia
-Facial droop
-Unilateral or bilateral weakness
-Ataxia
-Vision changes
-Headache
124
How often to check BP in stroke
-Every 15 minutes for 2 hours
-Every 30 minutes for 6 hours
-Every hour for 16 hours
125
BP goals for first 48 hours stroke
-No tPA: less than 220/110
-tPA: less than 180/105
-After 48 hours then gradually lower BP to outpatient BP goal
126
Hypertension management 48 hours after stroke
-Resume home antihypertensives (if applicable)
-If no home therapy, select therapy based on co-morbidities
127
Criteria to receive tPA
-Within 4.5 hours of symptom onset
-Ischemia stroke
-Do not give if BP is over 185/110 at time of administration
-Do not give if BG is less than 50
-Bleed risk
128
Alteplase dosing
-0.9 mg/kg IV
-Max 90 mg
-10% of dose given bolus over 1 minute
-90% given basal over 60 minutes
129
Tenecteplase dosing
-0.25 mg/kg IV
-Max 25 mg
130
Side effects of tPA
-Bleeding
-Cerebral edema
131
When to use aspirin for acute treatment of stroke
-First-line treatment
-All ischemic stroke patients initially unless contraindicated
-24 hours or more after tPA is administered
132
Aspirin acute stroke treatment dosing
High dose for 2-4 weeks
133
Aspirin monitoring
-Bleeding
-Stroke
134
When to use aspirin + clopidogrel in acute stroke treatment
Only in minor strokes (NIHSS less than or equal to 4)
135
When to use ticagrelor
-Data only in minor stroke (NIHSS 5 or less)
-Likely second line due to safety concerns
-Likely use for true aspirin allergy
136
When to use anticoagulants in stroke
If cardioembolic stroke or other indication for anticoagulant, recommended to start 2-14 days after stroke
137
How to reverse warfarin
IV vitamin K
138
How to reverse heparin products
Protamine
139
How to reverse DOACs
-Andexxa
-Dabigatran - idarucizumab
140
How to reverse antiplatelets
No antidote
141
BP goals for acute hemorrhagic stroke
-Goal BP first 24 hours: <180/110
-Goal BP 24-48 hours: <160/90
-Goal BP after 48 hours: outpatient goal
142
How to prevent cerebral vasospasm
Nimodipine 60mg orally q4h for 21 days after subarachnoid hemorrhage
143
When to use anticonvulsants in stroke
Only if the patient has a documented seizure history
144
First line treatment for secondary prevention of stroke
-Aspirin
-Aspirin + dipyridamole
145
Aspirin + dipyridamole side effects
-Headache (dose limiting)
-GI bleeding
146
Clopidogrel place in secondary stroke prevention
-Second line treatment in non-embolic ischemic stroke
-Aspirin intolerant patients
-Mostly used in combo with aspirin
147
Clopidogrel + aspirin place in secondary stroke prevention
-Atherosclerotic ischemic stroke
-Minor strokes (NIHSS 3 or less): first line treaetment
-Moderate-severe strokes: second line
148
Anticoagulants to use in mechanical mitral valve/LV thrombus
-Warfarin
-Rivaroxaban
149
Long-term BP goal for all patients with a history of stroke
Less than 130/80
150
Antihypertensives to use in patients who are black and have a history of stroke
-CCB
-Thiazide
151
Antihypertensives to use in patients who have CKD and a history of stroke
-ACEi
-ARB
152
Antihypertensives to use in patients who have CAD and a history of stroke
BB + ACEi (or ARB)
153
Antihypertensives to use in patients who have diabetes and a history of stroke
-ACEi
-ARB
154
Antihypertensives to use in patients who have HFrEF and a history of stroke
-ARNi/ARB/ACEi
-ARB + BB + aldosterone antagonist
155
Antihypertensives to use in patients who have Afib and a history of stroke
-BB
-Non-DHP CCB
156
LDL goal in stroke patients
Less than 70
157
When to use statins in stroke patients
-High-intensity statin in atherosclerotic ischemic stroke
-Do not use statin if cardioembolic stroke or hemorrhagic stroke
158
How to reduce risk of future strokes
-Cessation of illicit drugs
-Reduction of alcohol consumption
-Diabetes control
-Physical activity
-Diet
-Weight loss
-Smoking cessation
159
Antidepressants to avoid in stroke patients
-Paroxetine
-Tricyclic antidepressants
160
Examples of Drugs that induce lupus
-Methimazole
-Propylthiouracil
-Methyldopa
-Minocycline
-Procainamide
-Hydralazine
-Anti-TNF agents
-Terbinafine
-Isoniazid
-Quinidine
161
Signs and symptoms of lupus
-Fatigue
-Depression
-Photosensitivity
-Joint pain
-N/V
-Fever
-Weight loss
-Malar "butterfly" rash
162
How to diagnose lupus using SLICC
Must meet 4 or more features with one from each group
163
How to diagnose lupus using EULAR/ACR
Patient's score is 10 or more AND at least 1 clinical criterion is fulfilled
164
Key labs for lupus
-Anti-nuclear antibody (ANA)
-Anti-double-stranded DNA (Anti-dsDNA)
-Anti-Smith Antibody (Anti-SM)
-Antiphospholipid Antibody
165
Pharmacologic treatments of lupus
-Hydroxychloroquine
-NSAIDs
-Glucocorticoids
-Immunosuppressants
-Biologics
166
Hydroxychloroquine place in lupus therapy
Recommended for ALL patients with SLE
167
Hydroxychloroquine dosing
200-400 mg PO daily
168
NSAID place in therapy for lupus
Considered the first line for mild symptoms
169
NSAID dosing for lupus
-Ibuprofen: 400-600 mg PO q6-8h
-Naproxen: 500 mg PO BID
170
NSAID side effects
-GI bleed, gastritis, perforation
-Increased BP
-Worsened HF
-CV events
-Increased SCr, renal toxicity
-Hepatotoxicity
171
NSAID monitoring parameters
-CBC
-LFTs
-SCr
-BP
-S/sx of fluid retention and bleeding
172
Glucocorticoid place in therapy for lupus
Adjunctive treatment if not responsive to NSAIDs or hydroxychloroquine
173
Oral glucocorticoid dosing
-Mild-moderate disease: 5-30 mg/day
-Severe: 1 mg/kg/day
174
IV glucocorticoid dosing
Pulse therapy: 500-1000 mg IV daily x 3-6 days, then PO prednisone
175
What topical glucocorticoids would you use on the face?
Low-potency: fluocinolone valerate and hydrocortisone butyrate
176
What topical glucocorticoids would you use on the trunk/extremities?
Moderate potency: Triamcinolone and betamethasone
177
What topical glucocorticoids would you use on scalp sores and palms?
High potency: Clobetasol
178
PO/IV glucocorticoid side effects
-Glaucoma
-Increased BP
-Increased risk of osteoporosis
-GI bleed
-Gastritis
-Psychosis/sleep disturbances
-Weight gain
-Increased BG
-Increased risk of infection
-Cushing syndrome
179
Topical glucocorticoid side effects
-Skin atrophy
-Rosacea
-Telangiectasis
180
Glucocorticoid monitoring
-BP
-BMP every 6 months
-FLP every 6 months
-Bone mineral density annually
181
Immunosuppressant place in lupus therapy
-Adjunct to steroid therapy to lower the dose
-Insufficient response to HCQ
182
Immunosuppressant medications for lupus
-Methotrexate
-Azathioprine
-Cyclophosphamide
-Mycophenolate mofetil
183
Methotrexate lupus dosing
5-15 mg once weekly
184
Methotrexate side effects
-BMS
-Infection
-Renal
-GI
-Liver
-Pulmonary
-Hypersensitivity
-Dermatologic
185
Mycophenolate dosing for lupus
1-1.5 g BID
186
Mycophenolate side effects
-BMS
-Infection
-Malignancy
-AIS
-GI
187
Cyclophosphamide dosing for lupus
-1-1.5 mg/kg once daily PO
-0.5/m2 BSA every month for 6 months IV
188
Cyclophosphamide side effects
-BMS
-Infection
-Malignancy
-Cardiac hemorrhagic cystitis
-Liver
-Pulmonary
189
Azathioprine dosing for lupus
50 mg daily
190
Azathioprine side effects
-BMS
-Infection
-Malignancy
-N/V/D
-Liver
-Pancreatitis
-Monitor: TPMT deficiency
191
Biologics used for lupus
-Belimumab
-Rituximab
-Anifrolumab
192
Biologics place in lupus therapy
-Inadequate response to hydroxychloroquine and immunosuppressants
-Severe disease
193
Contraindications to biologics
-No live vaccines 30 days before starting therapy OR during therapy
-Do not use more than 1 biologic at the same time
194
Belimumab dosing for lupus
10 mg/kg every 2 weeks for 3 doses
195
Anifrolumab dosing for lupus
300 mg every 4 weeks
196
Rituximab dosing for lupus
-1 g on days 0 and 15
-375 mg/m2 once weekly for 4 doses
197
Nonpharmacologic treatment of lupus
-Balance of rest and exercise
-Smoking cessation
-Limit sun exposure and use of sunscreen
198
First line for cutaneous lupus
-Topical agents: GC and CNI
-HCQ
-Systemic GC
199
Treatment for refractory cutaneous lupus
-High-dose GC
-MTX
-MMF
200
How to treat mild to moderate lupus nephritis
GC +/- another immunosuppressant (AZA, MMF, or CNI)
201
How to treat severe lupus nephritis
-Mycophenolate or cyclophosphamide +/- GC
-Belimumab + MMF or CYC +/- GC
-CNI + MMF +/- GC
202
How to give contraception to people with lupus
-Avoid estrogen-containing contraception
-Screen for antiphospholipid syndrome
203
Potential risks for pregnant patients with lupus
-Miscarriage
-Fetal growth retardation
-Maternal mortality
-Preeclampsia
-Best prognosis is when the patient achieves remission for 6 months or more before pregnancy
204
Safe drugs to use in pregnant patients with lupus
-Hydroxychloroquine (drug of choice)
-NSAIDs
-Glucocorticoids
-AZA discuss risk vs benefit with provider
205
What is antiphospholipid antibody?
An autoimmune disorder characterized by antiphospholipid syndrome that can cause blood clots and miscarriages
206
How to treat an acute thrombotic event or patients with a history of thrombosis in lupus patients with antiphospholipid antibody
LMWH
207
Prophylaxis treatment for pregnant lupus patients with antiphospholipid antibody
-No prior fetal loss: aspirin 81 mg
-Recurrent fetal loss: aspirin 81 mg +/- LMWH
208
What is gout?
Inflammatory process in response to crystallization of monosodium urate in articular and non-articular tissues
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What is hyperuricemia?
Uric acid levels over 6.8 AND symptomatic
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Risk factors for gout
-Male
-Post-menopausal women
-Elderly
-Obesity
-Sedentary lifestyle
-Renal impairment
-Genetics
-Dietary/alcohol intake
-Socioeconomic factors
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What can cause overproduction of uric acid?
-Regulatory enzyme variability
-Cytotoxic medications
-Increase dietary intake of purines
-Chronic alcohol intake
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What can cause under excretion of uric acid?
-Dehydration
-Insulin resistance
-Acute alcohol intake
-Medications
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Signs and symptoms of gout
-Fever
-Intense pain
-Erythema
-Warmth
-Edema
-Inflammation of affected joints
-Podagra - first metatarsal joint often involved
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Laboratory tests associated with gout
-Elevated uric acid (over 6.8)
-WBC over 11,000
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Complications associated with gout
-Tophi - deposits of monosodium urate
-Nephrolithiasis - kidney stones
-Gouty nephropathy - acute and chronic kidney disease
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How to diagnose gout
-Synovial fluid aspiration (painful and expensive)
-EULAR
217
Non-pharmacologic treatment of acute gout attacks
-Modification of risk factors over time
-Applying ice to the affected area to reduce pain
-No supplements have shown benefit
218
Pharmacologic therapy for acute gout attacks
-NSAIDs
-Corticosteroids
-Colchicine
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NSAIDs used for gout
-Indomethacin
-Naproxen
-Ibuprofen
-Sulindac
220
Corticosteroid considerations for gout
-Taper PO courses
-Limit treatment duration
-Increased risk of GI bleed and peptic ulcer disease
-Close monitoring of diabetes
-Avoid IA injection if suspect infection
221
How to dose colchicine
-Day 1: 1.2 mg PO once, then 0.6 mg one hour later
-Day 2+: 0.6 mg BID until attack resolves
-CrCl less than 30: 1.2 mg at onset, 0.6 mg 1 hour later
-Dialysis: single 0.6 mg dose; treatment course should be repeated no more than once every 2 weeks
-Severe hepatic impairment: do not repeat more than once every 2 weeks
-Administer within 24 hours of acute attack
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Colchicine adverse effects
-Nausea
-Vomiting
-Diarrhea
-Neutropenia
-Axonal neuromyopathy
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Colchicine drug interactions
-CYP3A4 inhibitors
-PGP inhibitors
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What to do if inadequate initial response to colchicine
-Switch agents
-Add a second recommended agent (avoid NSAIDs with PO corticosteroids)
-Corticotropin, anakinra, canakinumab
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Non-pharmacologic treatment for chronic gout
-Weight loss if overweight or obese
-Dietary approaches to stop hypertension
-Alcohol restriction
-Limit purine rich foods (high fructose corn syrup, organ meats and some seafood)
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Indications to start ULT
-2 or more gout flares per year
-1 or more tophus
-Radiographic evidence of damage attributable to gout
-More than 1 flare, but infrequent
-Patients experiencing first flare in the presence of CKD stage 3-5, uric acid over 9, urolithiasis
227
Who is not a candidate for ULT?
-Asymptomatic hyperuricemia with no prior gout flares or tophi
-First gout attack without risk factors
228
When to initiate ULT?
During an acute gout attack
229
How long should ULT be given?
Indefinitely
230
Pharmacologic therapy for chronic gout
-Allopurinol (first line)
-Probenacid (second line)
-Pegloticase (third line)
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Allopurinol dosing
-Initial dose: 100 mg PO daily
-Titrate every 2-4 weeks in 100 mg or less increments to achieve a uric acid level of less than 6
-Max dose of 800 mg/day
-eGFR less than 60: initial dose 50 mg daily
232
Allopurinol drug interactions
-Loop and thiazide diuretics
-Warfarin
-Azathioprine, fluorouracil products, mercaptopurine, didanosine
233
Allopurinol ADRs
-Skin rash
-Headache
-Urticaria
-Hepatotoxicity
-Hypersensitivity reaction (Stevens-Johnson syndrome) (toxic epidermal necrolysis)
234
Risk factors for allopurinol hypersensitivity syndrome
-Female
-Age over 60
-High initial doses
-CKD
-CV disease
-HLA-B*5801 allele + (non whites)
235
Allopurinol monitoring
-Uric acid every 2-5 weeks while titrating, every 6 months when stable
-Renal function
-LFTs
236
Counseling for allopurinol
-Drink plenty of fluids
-Take this medication even when you do not have gout symptoms
237
Febuxostat BBW
Increased cardiovascular mortality
238
Probenecid ADRs
-GI irritation
-Rash
-Urolithiasis - CI in patients with history
239
Probenecid cautions
-G6PD deficiency
-Not recommended in eGFR less than 60
240
Probenecid drug interactions
-Penicillins
-Cephalosporins
-Sulfonamides
-Indomethacin
241
When to use pegloticase
-Severe gout and hyperuricemia
-3 or more gout flares within 18 months
-1 or more tophi
-Joint damage due to gout
-IV infusion
242
Pegloticase BBW
-Anaphylaxis and infusion-related reactions
-G6PD deficiency-associated hemolysis and methemoglobinemia
243
Pegloticase ADRs
-Constipation
-Nausea
-Vomiting
-Chest pain
-Nasopharyngitis
244
Pegloticase pearls
-Immunogenicity - patients may develop antibodies that result in lack of efficacy
-Screen patients at risk for G6PD deficiency (non-whites)
245
Pharmacologic therapy for gout flare prophylaxis
-NSAIDs at the lowest effective dose
-Prednisone
-Colchicine
246
Colchicine prophylactic dosing
-CrCl 30 or more: 0.6 mg once or twice daily
-CrCl less than 30: 0.3 mg daily (consider alternate therapy)
-Dialysis: 0.3 mg twice weekly (consider alternate therapy)
