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Lymphoreticular > Immune-Mediated Dz Tx > Flashcards

Immune-Mediated Dz Tx Flashcards

1
Q

Necessary adjunctive therapies for IMD?

A
  • diet
  • topical tx and gastrointestinal barrier protection for steroid (only if indicated w/ concurrent liver/spleen dz etc. or thrombocytopenia d/t ^ risk of bleeding from ulcer)
  • blood products (esp anaemia) Darbopoietin (erythropoetin substitute)
  • ? Danazol (androgen, not used much now, min evidence)
  • ? Plasmapheresis (high level establishments, emergency only with intractable haemolysis etc)
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2
Q

What should be cautioned with steroids and nutrition?

A
  • PEG tube risks

- v fibrous tissue formation so when removed septic peritonitis will ensue

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3
Q

Outline nursing care needed for IMD. LOOK UP

A 
> recumbency
- UD, hygeine, excercie
> physical signs of deterioration 
- analgesia, comfort
> nutrition
- naso-oesophageal, oeseophageal, PEG 
> water
> IV catheter care and fluid tx
> diagnostic samples
> client comms
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4
Q

How do corticosteroids function on a cellular level?

A
  • associate with binding proteins (transcortin and albumin)
  • dissociate, passively diffuse into cell
  • bind to cytoplasmic receptors (>3)
  • conformational change of R unmasks DNA binding domains
  • associates with GREs following nuclear translocation
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5
Q

CEellular targets of corticosteroids?

A 
> inflam cells
- eosinophils
- T cells
- mast cells
- macrophages
- denritic cells 
> structural cells
- epithelium
- endothelium 
- airway smooth muscle 
- mucous glands
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6
Q

How do different corticosteroids differ?

A
  • GC and MC activity
    > dexamethasone NO MC activity, potent GC
    > prednisone/prednisolone GC and MC
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7
Q

How do seroids in US and UK differ?

A
  • Prednisolone used for everything UK

- PrednisONE USA

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8
Q

How does potency, duration or action and dose of the 3 main corticosteroids differ? LOOK UP

A 
> prednisolone
- potency 1
- dose 2-4mg/kg/d
- DOA 12-36 
> methylpred
- 1.25
- 2-4
- 12-36
> dex
- 7-10
- 
-
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9
Q

Potential adverse effects of immunosuppressive doses of steroids?

A

> worse in dogs, WARN OWNERS!!!

  • sarcopenia (muscle melt away)
  • GIT (esp ulceration)
  • MC activity -> fluid retention etc. (pred and methyl pred) contraindicated for CHF
  • metabolic effects (bone density)
  • Cushingoid appearance after 2-3weeks
  • immune vulnerability
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10
Q

What other immunosuppressive drugs (other than steroids) can be used for IMD? What stages of the cell cycle do they act at?

A 
> Mitosis phase 
- Vinca alkaloids (eg. vinblastine)
> GI
- calcinuerin inhibitors (eg. cyclosporine)
- leflunomide
~ G1-S rapamycin (not used vet)
> S
- steroids
- antimetabolites
- mycophenolate mofetil
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11
Q

How do alkylating agents work? LOOK UP

A
  • cross-links twin strands

- inhibits protein synthesis in resting cells, prevents mitosis, kills dividing cells

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12
Q

Egs of alkylating agents?

A

> cyclophosphamide
- now no longer advocated, only for CHOP lymphoma
ifosphamide
chlorambucil
- minimally toxic, min side effects (myelosuppression)
melhalen, mechlorethamine, nitrosoureas
procarbazine, decarbazine

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13
Q

Outline cyclophospmahde

A
  • dont use
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14
Q

Overview of chlorambucil

A
  • rapidly metabolised (mustard thing)
  • slowest acting and least toxic of all alkylating agents
  • myelosupression only when admin >1 month
  • urinary and feacal excretion
  • administer without food
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15
Q

Which immunosuppressive drug is contraindicated in cats?

A

Azathioprene (irreversiple BM suppression)

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16
Q

Overview of azathioprene

A
  • greater effeect on cellular than humoral immunity
  • hepatic metabolism
  • competes with endogenous A and G nucleotides -> non-fucntional nucleic aid strands
  • slow immunosuppressive effect
  • haaem, GIT, hepatic +- neuromuscular toxicity (can exacerbate MG)
17
Q

What can azathioprene be used alongside?

A

Steroids

18
Q

Where are vinca alkyloids derived from? Whih are the 2 most common?

A

> common periwinkle plant!

- vincristine and vinblastine (though blastine not used for IMD)

19
Q

How do vinca alkaloids work? ROA?

A
  • bind tubulin, block polymerisation
  • breakdown preformed microtubules and ^ rate of PLT release from megakaryocytes
    > esp good for IM thrombocytopenia (^no. platlets)
  • bolus IV, or to preload PLTs
  • severe extra-vascular vesicants (get it in the vein!!)
20
Q

How must vinca- alkaloids be given? Side effects?

A
  • IV
  • severe extra-vascualr irritation and sloughing
    > warm compress and flush saline if injected wrong
    > side effects:
  • haem
  • GIT
  • neurological tox (megacolon/megaoesophagus w/ repeated dosing)
21
Q

Vincristine and vinblastine. ALternative drug that is not used d/t severe neutropenia?

A

> Vinorelbine

- Semi-synthetic derivative of vinblastine, neutropenia

22
Q

Lic calcineurin inhibitiros?

A
  • Atopica for atopic derm (Ciclosporin)

- Tacrolimus (Anal furunculosis topically)

23
Q

Cilosporin and dosing

A
  • IV and oral forms
  • large volume of distribution and 1* hepatic metabolism
  • should probably monitor drug conc (peak @ 2hrs post administration, acute and chronic)
24
Q

How can dose of ciclosporin be decresed? Side effects?

A

> Give ketoconazole to inhibit hepatic metabolism
SIde effects
- renal, GI, heptic
- hirsuitism, gingival hyperplasia, paillomatosis
+- diabetogenic (CI in diabetic patients)

25
Q

How can GIT side effecs of ciclosporin be reduced?

A

Feed with some food

26
Q

What is IVIG? Side effects?

A
  • intravenous immunoglobulin (human) Minimal evidence
  • polyspecific IgI derived from healthy donor plasma
  • 1* use in human medicine tx of immunodeficiency
  • blockade of Fc receptors on mononuclear phagocytic cells (rapid repsonse)
  • inhibits phagocytosis of Ab-coated canine RBCs (involved in extravascular breakdown)
  • possible role in tx IMHA, IM non-regenerative anaemia, pure red cell aplasia, ITP, EM, TEN, SARDS
    > thromboembolism and hypersensitivity and hypertension possible (blood product, so give slowly)
  • high cost, limited availability
27
Q

Mechanism of action IVIG

A
  • IgG from healthy donors
28
Q

Mycophenolate mofetil overview

A
  • fast
  • IV
  • more GI effects
    ~= azothioprene
  • purine synth antagonist
29
Q

Initial tx for IMD?

A

> prednisone/prednisolone

  • @3-4mg/kgPO (cats tolerate better)
  • Max dose dogs >30kg (50-60mg/m^2)
30
Q

What concurrent tx should be considered for initial tx IMD? In what situations?

A

> potential for occult rickettsial/protozoal infection
- doxycline + water flush (stricture formation possible)
if IMHA or aggressive IMD
- adjunctive from outset (azathioprene in dogs, chlorambucil in cats)
MG (myasthenia gravis)
- cholinesterase inhibitors instead and titrate low dose upwards (rather than starting high dose)
always consider comorbidities

31
Q

How long is clinical response assessed over?

A

7d

32
Q

If response poor after 7d, what do you do? LOOK UP

A
  • add adjunctive immunosuppressant
  • if combo used from start, consider vincrsinte, hIVIG etc.
    > beware occult infection, neoplasia and iatrogenic causes that you may have missed!!
  • always consider supportive measures eg. fresh whole blood, PLT-rich plasma
33
Q

How often should CBC and UA be repeated? What else should/could be monitored depending on case?

A
  • q7-14d
  • look at urine sediment)
  • synovial fluid
34
Q

DOsing regime and reductino rate of corticoseroids?

A
  • 20-25% decerase in dose q4-6weeks as long as clinical remission maintained
  • do nto alter adjunctive tx at the same time as steroids UNLESS ESSENTIAL (eg. fulminant infection)
  • if signs recurr, return to previous dose and attemt reintroduction of remission more slowly
35
Q

Stopping corticosteroids…

A
  • can be stopped altogether if clinical remission persists
  • cautious tapering of any additional agents atetmpted over following 2-3months
    > if several immunosuppressants ued at once only do one at a time
36
Q

Which antiepileptic drug has potential immune-mediated reactions assocate with it?

A
  • phenobarb
37
Q

When is prognosis worsened for immunemediated dz patients?

A
  • 2* infection
38
Q

General tx principles of IMD?

A
  • halt ongoing damage, satisfy nutritional and nursing needs
  • non-sepcific immunosuppression mainstay
  • corticosteroids form mainstay of tx, various adjuncts helpful
  • novel agents potential for more potent and targetted immunosuppression

Lymphoreticular (31 decks)

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