Immunosuppressive Drugs (IBD & RA) Flashcards
Tofacitinib, Baricitinib, Upadacitinib (RA)
RA
- JAK-i (oral)
- if inadequate response to TNF-i +/- MTX
- Don’t use in hepatic impair, malignancy, infection, MACE risk, thrombosis, GI perf
- Don’t use in: Hbg<9, ANC<1000, ALC<500 (monitor these)
AE: URI, HA, Nausea
Severe-Fulminant UC
- IV Methylprednisolone or HCT –>PO Pred
- Inflix or cyclosporin if unresponsive to IV steroids (bridge cyclo to AZA/6-MP)
CD Maintenance of Remission
- 1st: Inflix or Adalimu +/- AZA/6-MP
- 2nd: certoliz, vedoliz, ustekin, risankiz
Mesalamine (5-ASA)
- Not effective in CD (last resort Tx)
- DI: bleed risk, PPI/H2RA/Antacid
- Absorped in small intestine, not colon
Golimumab (Simponi)
UC
- TNF-i
- SQ q4week
Mod-Severe CD
- acute Tx with PO Pred
- 1st: Inflix +/- AZA
- 2nd: Adalimu +/- AZA
- 3rd: Vedo, Ustekin, Risankiz, or Upadacit
Leflunomide
- Needs loading dose (PO QD)
- AE: Teratogenic, inc LFTs, rash, D
- Monitor: CBC, SCr, LFts
Abatacept (Orencia)
RA
- T-cell-i/co-stimulation modulator
- IV q4week +/- MTX
- if failed other DMARD
- caution in COPD pts
Mild-Mod CD
- Budesonide CR x8-16w (if distal or right-sided)
- Sulfa and Mesa not effective
Tocilizumab (Actrema)
RA
- IV q4week (MAX: 800 mg)
- BLACK BOX: serious infections
- AE: inc LFTs, thrombocytopenia, neutropenia, lipid abnormalities, GI perf (monitor these)
- CI: liver tox, thrombocytopenia, neutropenia
Sarilumab (Kevzara)
RA
- IL-6-i
- SQ q2week
- BLACK BOX: serious infections
- AE: inc LFTs, thrombocytopenia, neutropenia, lipid abnormalities (monitor these)
- CI: liver tox, thrombocytopenia, neutropenia (dec dose to 150 mg)
Natalizumab
CD (SUCKS)
- inhibits leukocyte migration (anti-integrin)
- PML risk!! (check JC antibody)
- NOT used in combo w/ other IBD drugs
- D/C if not benefit
Upadacitinib (Rinvoq)
UC and CD
- JAK-i
- ONLY if pt had inadequate response/failure to TNF-i
- AE: neutropenia, lymphoma, anemia, inc LFTs
- poss TERATOGENIC
- BLACK BOX: increase
mortality, CV events,
clots, malignancy
- Monitor: lipids, skin
- D/C after 16 weeks if inadequate response
Rituximab
RA
- anti CD20 antibody
- two IV inf 2 weeks apart
- admin methylpred 30 mins prior
- AE: TLS, renal tox, bowel obstruction, Hep B, arrhythmia, hypersensitivity
- Monitor: CBC w/ plts, SCr, Vitals
Sulfalazine (IBD)
- Monitor: CBC, LFTs
- DI: NSAIDs/Anticoags
- AE: HA
Corticosteroids (IBD)
- Remission only and flare ups
- PO Pred
- CR budesonide
- IV Methylprednisolone
Risankizumab (Skyrizi)
UC and CD
- Selective IL-23 antagonist
- Hepatotoxic/ inc in LFT
- possible inc in lipids
- IV then SQ
Mild-Mod UC
- Extensive: oral mesalamine
- Left sided: topical mesa enema
- Proctitis: suppository
- CR Budesonide (x8-16w) or PO Pred
- Combo oral + topical best for left/extensive
Biologics AE/Monitoring
- ADR: infection risk, malignancy risk (lymphoma), HSTCL, CHF exacerbations, hepatoxicity
- Monitor: CXR, Hep B/C, CBC, LFTs, Lytes, CRP, TDM
Ustekinumab (Stelara)
UC and CD
- IL-12 and IL-23 antagonist
- Cutaneous cell carcinoma in pts w/ risk factors
- possible neurotox (RPLS/PRES) and CV events
- Monitor: Skin, CV, Neuro
RA Adjunct
- never MonoTx
- NSAIDs or Corticosteroids
- Celecoxib CI’d in sulfa Ax
- use corticosteroids for shortest time as possible
Anakinra
RA
- IL-1-i
SQ QD +/- MTX
- if failed other DMARD
- if CrCl<30–> SQ every other day
- AE: dec neutrophils (monitor)
Methotrexate (RA)
DMARD D.O.C
- start 7.5 mg SQ weekly
AE: bone marrow suppression, NVD, stomatitis (1mg FA QD), hepatic, pulmonary, teratogenic
- CI: Pregnancy, Liver disease, CrCl<40, blood dycrasias, pleural effusions
- Monitor CXR, CBC, SCr, LFTs. Albumin
Mod-Severe UC
1st Line: TNF-i, Vedo, or Ustekin WITH AZA
- Biologics if unresponsive to Mesa/Pred
- TNF-i: Inflixi, adalimu, golimumab
- Anti-integrin: Vedolizumab
- IL-i: ustekin, mirikizu, risanki
- JAK-i: Upadac, tofacit
- SP1-i: Ozanimod, estrasimod
- Thiopurines MonoTx for maintenance poss
