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Therapeutics > Exam 4 lecture 7 > Flashcards

Exam 4 lecture 7 Flashcards

1
Q

Define lupus

A

Chronic autoimmune disease with diverse clinical presentation.
Immune system attacks healthy tissue and organs throughout the body.
Control of this disease remains a challenge

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2
Q

Predisposing factors to lupus

A

Genetics- 1st degree relatives; 20 x more likely to develop SLE

Hormonal- Estrogen production may modulate the incidence and severity of SLE

Env’t- CIgarette smoking, meds, UV light, air pollution, ciruses, stress, pesticides

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3
Q

What is Drug induced lupus erythematosus (DILE)? WHen do symptoms occur? When does resolution occur?

A

Overreaction to certain meds
symptoms occur 3-6 months of drug initiation
Resolution occurs within weeks of drug dx

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4
Q

What us a mnemonic to memorize drugs that cause DILE

A

My Pretty Malar Marking Probably Has A TransIent Quality

Every capital letter is a drug (including the I in transiet)

Methimazole
Propylthiouracil
Methyldopa
Minocycline
Procainamide
Hydralazine
Anti-TNF agents (infliximab and etanercept)
Terbinafine
Isoniazid
Quinidine

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5
Q

s/s of lupus (SLE)

A

Fatigue
Depression
Photosensitivity
Joint pain
N/V
Fever
Weight loss
Malar “butterfly” Rash

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6
Q

What are some mucocutaneous s/s of SLE?
Opthalmologic?
Renal?

A

mucocutaneous- butterfly rash, discoid rash, raynaud phenomenon

Opthalmologic- Lupus retinopathy

Renal- Lupus nephritis

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7
Q

What is Raynaud Phenomenon

A

Exaggerated vascular response to cold temperature or emotional stress

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8
Q

What are the two diagnostic tools that will be used for lupus

A

SLICC
EULAR

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9
Q

How does SLICC criteria work

A

Must meet > 4 total features with 1 from each group

OR

Biopsy proven lupus nephritis WITH systemic lupus

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10
Q

criteria for EULAR

A

Patients score is > or = 10 AND atleast 1 clinical criterion is fulfilled

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11
Q

What are some key labs for SLE? WHat is a normal range? WHat is its specificity?

A
  1. Anti-nuclear antibody (ANA)- reference range (<1:40)= negative. Positive in lupus patients but not specific
  2. Anti double stranded DNA (Anti-dsDNA)- Negative, High specificity (correlates with disease activity and is an important marker in lupus nephritis)
  3. anti- smith antibody (Anti-SM)- negative- High specificity for diagnosis
  4. Antiphospholipid antibody- negative, increases clotting factors
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12
Q

What are 5 drug classes that patients will be on when they have lupus?

A

Hydroxychloriquin (HCQ)
NSAIDs
Glucocorticoids
Immunosuppressnats (IS)
Biologics

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13
Q

MOA of HCQ? Place in therapy? Benefit of HCQ? Dosing (exam)

A

MOA- anti malaria-> inhibit overactive immune cells

Place in therapy- Recommended for ALL pts with SLE

Benefits- reduces flares and help manage pain

Dosing- 200-400mg PO daily

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14
Q

Side effects of HCQ

A

-opthalmic: retinal toxicity (bulls eye maculopathy)
-Hemolytic anemia if you have G6PD deficiency
- CNS (depression, anxiety)
- CV- QT prolongation
- HS rxn

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15
Q

What type of disorder is G6PD deficiency

A

X-linked disorder that causes RBCs to prematurely break down (happens more in males)

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16
Q

What drug do we not give if patient has G6PD deficiency

A

HCQ

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17
Q

Monitoring parameters for HCQ

A

CBC
LFTs
SCr
EKG

Periodic eye exam 3 onths after eye exams and annually there after

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18
Q

MOA of NSAIDs? Benefits? Place in therapy?

A

MOA- inhibits COX 1 and 2 to decrease the formation of prostaglandin precursor

Benefits- Antipyretic, anti-inflammatory and analgesic

Place in therapy- 1st line for mild symptoms

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19
Q

Dosing of Ibuprofen and naproxen

A

Ibuprofen- 400-600 mg PO Q 6-8 H
Naproxen- 500 mg PO BID

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20
Q

Side effects of NSAIDs

A

GI bleeding, gastritis or perforation
CV- increased BP,worsening HF, CV events
Renal- increased Scr, renal toxicity
Hepatic- Hepatotoxicity

21
Q

Monitoring parameters for NSAIDs

A

CBC
LFTs
SCr
BP
S/sx of fluid retention and bleeding

22
Q

Glucocorticoid MOA? Benefits? Place in therapy?

A

MOA: Inhibits B and T cell responses
Benefits: Anti inflammatory and helpful during flares
Place- adjunct treatment if not responsive to NSAIDs, HCQ

23
Q

Dosing of oral glucocorticoid (prednisone)

A

MIld-moderate disease: Prednisone 5-20 mg/day
Severe: 1 mg/kg/day

24
Q

IV dosing of glucocorticoid

A

Methylprednisolone: 500-1000 mg IV x 3-6 days then PO prednisone

25
Q

For topical glucocorticoids, name low potency, moderate potency and high potency glucocorticoids and where they are used

A

low potency: Flucinolone and hydrocortisone butyrte (face)

Moderate: Triamcinalone and Betamethasone (Trunk and extremities)

High potency: CLobetasol (scalp sores and palms)

26
Q

PO/IV glucocorticoids side effects

A

Opthalmic: glaucoma
CV: increased BP
Bone: Increased risk of osteoporosis
GI: GI bleed
CNS: Psychosis/sleep disturbances
Cushings syndrome
weight gain

27
Q

Topical glucocorticoids side effets

A

Skin atrophy, rosacea, telengiectasis

28
Q

Monitoring for glucocorticoids

A

Baseline: BP, BMP, FLP, BMD

ROutine
BMP q 6 mo
FLP 6 mo
BMD: annually

29
Q

Immunosuppressants MOA? Place in therapy? Meds?

A

MOA- suppression of immune system from attacking healthy cells
Place in therapy: Adjunct to steroid therapy to lower the dose or insufficient response to HCQ

meds: Methotrexate
Mycophenolate
cyclophosphamide
azathroprine

30
Q

Methotrexate dosing? side effects?
Mycophenolate dosing? Side effects?

A

Methotrexate: 5-15 mg once weekly. May cuse BMS, infection

Mycophenolate: 1-1.5 g BID, BMS, infection, malignancy, AIS

31
Q

Cyclophosphamide dosing and side effects?

Azathioprine Dosing and side effects?

A

Cyclophosphamide: 1 - 1.5 mg/kg once daily
IV: 0.5 mg/m2 BSA q month c=x 6 months
side effects: BMS, infection, malignancy

Azathioprine: 50 mg daily
BMS, infection, malignancy

Monitor for TPMT deficiency in azathioprine

BMS= bone marrow suppression

32
Q

Biologics MOA? Place in therapy? Medications?

A

MOA: Monoclonal antibodies that block B cell mediated immunity

Place in therapy:
- inadequate response to antimalarial and immunosuppressants
- severe disease

Medication
-Belimumab
- rituxiamb
- anifrolumab

33
Q

Pearls with biologics with lupusq

A

No live vaccines 30 days before starting therapy OR during therapy

Do not use more than 1 biologic at the same time

34
Q

Belimumab dosing? Side effects?

A

10 mg/kg every 2 weeks x 3 doses

HS and infusion rxn

35
Q

Anifrolumab dosing and side effects

A

300 mg every 4 wks, HS rxn

36
Q

Rituximab dosing? Side effects?

A

1g on days 0 and 15 or 375 mg.m2 once weekly for 4 doses

Side effects- Infusion rxn, Hep B reactivation, ML

premedicate 30 mins prior to administration

37
Q

What is an additional biologic that can be used in lupus

A

Calcineurin inhibitors (CNI)
- tacrolimus
- vocolosporin (oral lupus med)

38
Q

non pharm adjustments for lupus

A

Balance of rest and exercise
Smoking cessation
Limit sun exposure and use fo sun screen

39
Q

How common and dangerous is cutaneous lupus? First line treatmemnt? Refractory treatment?

A

10% of lupus cses, rarely life threatening. Presents with rash and lesions

1st line:
1)TOpica; agents
- GC: clobetasol, betamethasone, hydrocortisone,triamcinalone

CNI: Tacrolimus, pimecrolimus

2)HCQ
3) systemic GC

Refractory
- high dose GC
MTX
MMF (mycophenolate)

40
Q

how common and dangerous is lupus nephritis? Therapy for class I/II lupus nephritis?

A

LN is a serious complication of SLE which can affect 6-% of patients within 10 yrs of diagnosis

Therapy
Mild/moderate nephritis
- GC+/- another immunosuppressive AZA, MMF or CNI

Severe nephritis
MMF (preferred) or CYC +/- GC
Triple therapy:
- belimumab + MMF or CYC +/- GC
CNI + MMF +/- GC

41
Q

Therapy for class III or IV lupus nephritis

A

-Glucocorticoid
+
-CNI + MPAA
or
-MPAA (Most preferred) (can have induction and maintenance)
or
- cyclophosphamide (2nd line after MPAA)
or
-Belimumab + MPAA or reduced dose cyclophosphamide

42
Q

Drugs for
FLuid retention
Pain and inflammation?

A

Diuretic

NSAIDs (recommend tylenol first)

43
Q

Compare healthy pregnancy vs lupus pregnancy? When is the best prognosis
COntraception?

A

Lupus pregnancies at more risk for
- miscarriages
- fetal growth retardation etc

Best prognosis is when the patient achieves remission for > 6 months

COntraception
- Avoid estrogen containing contraception
- Screen for antiphosholipif syndrome

44
Q

Which drugs are safe to use in pregancy? Which should we discontinue

A

HCQ ( safe throughout pregnancy)
NSAIDs ( discontinue at 20 weeks or later)
GC- safe throughout
MMF, CYC, MTX- contraindicated
AZA- risk vs benefit with proveider
Biologics- do not recommend

45
Q

What is antiphospholipid syndorme

A

An auto immune disorder characterized by antiphospholipid syndrome that can cause blood clots and miscarriages

46
Q

Prophylaxis for antiphospholipid antibody

A
  • no prior fetral loss- apsirin 81 mg
  • Recurrent fetal loss- aspirin 81 mg + LMWH

If acute thrombotic event/hx of thrombosis- LMWH

47
Q

Can we use warfarin in pregnant woman

A

NEVER

48
Q
A

Therapeutics (37 decks)

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