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Lectures / Presentations > Immunosuppression / Peds (Tan) > Flashcards

Immunosuppression / Peds (Tan) Flashcards

1
Q

Why do corticosteroids have increased ADRs? What explanation from its MOA?

A

It blocks the initial Interleukin-1 pathway (IL-1)
Targets antigen presenting cell (macrophage/monocyte) and blocks IL-1
All stages of T-cell activation are inhibited

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2
Q

What are the calcineurin inhibitors?

A

Tacrolimus (FK506)

Cyclosporine

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3
Q

What are the properties of mineralcorticoids, glucocorticoids, and corticosteroids?

A
  1. Mineralcorticoids = retain sodium
  2. Glucocorticoids = regulates glucose
  3. Corticosteroids = Mineralcorticoid + Glucocorticoid effects
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4
Q

Explain induction therapy with the chalkboard analogy

A

Immune system like a chalkboard
Induction erases board
Overtime board fill back up
Full does not completely fill, diminished immunity needed

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5
Q

What is a common methylprednisolone dose? Max?

A

2-30 mg/kg/DOSE

Max = 1000 mg/24hrs

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6
Q

What are examples of short-term ADR of corticosteroids? (7)

A
  1. Glucose changes (possibly induce diabetes)
  2. Depression, insomnia
  3. HTN, DLD
  4. Muscle weakness, osteoporosis
  5. Acne
  6. Growth suppression in children
  7. Increased appetite
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7
Q

What are examples of long-term ADR of corticosteroids?

A
  1. Buffalo hump

2. Moon face

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8
Q

What may be an adjunctive therapy for high dose corticosteroids?

A

H2 blocker for PUD

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9
Q

What are manifestations of addisonian crisis? (2)

A
  1. Hypotension

2. Hypoglycemia

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10
Q

What is the dose and times for lab draw with cosyntropin ACTH testing?

A

0.25 - 0.5 mg IV or IM
Draw baseline in AM
Draw level 30-60 min. after

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11
Q

Which cyclosporine is the modified? The oil based?

A 
Neoral = modified, newer
Sandimune = oil-based older
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12
Q

What immunosuppression pathway involves calcineurin?

A

Inhibits the production of IL-2

IL-2 is a critical cytokine that promotes T-cell activation

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13
Q

What is a common PO and IV dose range for cyclosporine?

A 
PO = 25-200mg (3mg/kg/DOSE) Q8-12H
IV = 0.05-0.3 mg/kg/hr as a continuous infusion or
IV = 1-2mg/kg/DOSE Q12H over 4 hours
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14
Q

What is a IV to PO consideration for cyclosporine?

A

3 fold increase in oral dose

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15
Q

What are ADRs for cyclosporine? (3)

A
  1. Nephrotoxicity (constricts afferent arteriole, blood to the kidney)
  2. Hypertrichosis (hair growth, remember the little girl with hair on her arms)
  3. Gingival hyperplasia
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16
Q

What are drugs that have gingival hyperplasia as an ADR? (3)

A
  1. Cyclosporine
  2. Phenytoin
  3. Diltiazem
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17
Q

What is a consideration for patients on cyclosporine and rapamycin/sirolimus?

A

Sirolimus can increase cyclosporine levels

Administer 4 hours apart from cyclosporine

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18
Q

What was tacrolimus initially investigated for (indications)?

A

It is macrolide-like, so initially investigated as an antibiotic

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19
Q

What is an IV to PO consideration for tacrolimus?

A

3 fold increase in oral dose

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20
Q

What is PO administration consideration for tacrolimus?

A

Must be taken on an empty stomach

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21
Q

Why aren’t infants typically treated with tacrolimus?

A

Must be taken on an empty stomach

22
Q

What to consider if switching from one to the other (tacrolimus or cyclosporine)?

A

Wait minimum 12 hours

23
Q

What are ADRs for tacrolimus?

A
  1. Nephrotoxicity (constricts afferent arteriole, blood to the kidney)
  2. Hypertension
  3. Glucose intolerance (not seen with cyclosporine)
  4. Alopecia (opposite of cyclosporine)
24
Q

What is the MOA for azathioprine?

A
  1. Inhibits purine nucleotide synthesis and metabolism of RNA
  2. Inhibits clonal expansion of T and B lymphocytes
25
Q

How are dose adjustments made with azathioprine?

A

According to WBC count

26
Q

How does allopurinol interact with azathioprine?

A

Inhibits the metabolism of azathioprine

27
Q

How is the Myfortic brand formulated?

A

Enteric coated mycophenolic acid

28
Q

Should mycophenolate dose be doubled for an acute rejection?

A

No

29
Q

What is unique about the metabolism of myophenolate mofetil?

A

It is a prodrug

30
Q

What is the MOA of mycophenolate mofetil?

A
  1. Inhibits inosine monophosphate dehydrogenase (IMPDH) a critical enzyme of guanosine nucleotide
  2. Guanosine nucleotide is needed for clonal expansion of T and B lymphocytes
31
Q

What is IV to PO for mycophenolate?

A

1:1

32
Q

What are the mTOR inhibitors?

A
  1. Sirolimus (Rapamune)

2. Everolimus 2nd generation (Zortress, Afinitor=Onc)

33
Q

What is the MOA of antithymocyte globulin?

A

Equine or rabbit polyclonal antibodies directed against circulating T lymphocytes

34
Q

Which animal are the antithymocyte globulin brands derived from?

A
  1. Atgam (Equine)

2. Thymoglobulin (Rabbit)

35
Q

What are the premedications for antithymocyte globulin?

A
  1. Methylprednisolone
  2. Diphenhydramine
  3. Acetaminophen
36
Q

What are ADRs for antithymocyte globulin?

A
  1. Cytokine release syndrome (fever, chills)
  2. Leukopenia (low WBC)
  3. Neutropenia (Low neutrophils, type of WBC)
37
Q

What is plasmapheresis?

A

Plasma dialysis

Removes harmful antibodies

38
Q

What is a intravenous immune globulin (IVIG) common dose?

A

2000mg/kg (single or divided)

39
Q

What is the target of rituximab?

A

CD 20 (only found on B-cells)

40
Q

What are examples of opportunistic infections and medications used for treatment?

A
  1. PCP = Bactrim
  2. CMV EBV = Valganciclovir
  3. Candida = Nystatin
41
Q

Do infants need induction therapy?

A
42
Q

Which immunosuppression agents can cause bone marrow suppression (decrease in WBC)?

A
  1. Mycophenolate
  2. Everolimus / Sirolimus
  3. Azathioprine (Imuran)
43
Q

How to double check which formulation of anti-thymocyte globulin (Atgam Thymoglobulin)

A
  1. Thymoglobulin is more potent (1.5mg/kg/dose)

2. Atgam could be an 10 fold higher (15mg/kg/dose)

44
Q

What medications can be considered for appetite stimulation? (3)

A
  1. Cyproheptadine (Periactin) (Antihistamine)
  2. Megestrol Acetate (Megace) (Anti-estrogen)
  3. Dronabinol (Marinol)
45
Q

When to check a sirolimus (Rapamune) level after dose change?

A

Can wait two weeks

It has a large volume of distribution

46
Q

During induction therapy what can be monitored which could lead to an early D/C of anti-thymocyte (Thymoglobulin)?

A

CD3 counts

47
Q

What is an non-invasive way to monitor for heart transplant rejection (other than biopsy)?

A

Echocardiogram

If EF is reduced it can be a warning sign

48
Q

Why are mTOR inhibitors avoided for 3-4 months after heart transplant?

A

Delayed wound healing
They should be held for elective surgery (2 weeks)
May change to mycophenolate (Cellcept)

49
Q

Does palivizumab (Synagis) act like a vaccine?

A
  1. No, it is a monoclonal antibody
  2. Gives passive immunity
  3. Does not provide long term vaccine benefit
50
Q

What immune globulin requires a diluent? How long is the process? Expiration?

A
  1. Carimune
  2. Gammagard (SD powder formulation)
  3. Sterile water as diluent
  4. Takes 1 hr to dissolve (nurses often call asking where it is)
  5. Once water hits the powder, it expires in 24 hours
51
Q

If you give IVIG will vaccines work?

A

No. Wait 4-6 weeks, IVIG will last that long

Lectures / Presentations (10 decks)

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