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Immunosuppressive Drugs (IBD & RA) Flashcards

1
Q

Tofacitinib, Baricitinib, Upadacitinib (RA)

A

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

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2
Q

Severe-Fulminant UC

A
  • IV Methylprednisolone or HCT –>PO Pred
  • Inflix or cyclosporin if unresponsive to IV steroids (bridge cyclo to AZA/6-MP)
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3
Q

CD Maintenance of Remission

A
  • 1st: Inflix or Adalimu +/- AZA/6-MP
  • 2nd: certoliz, vedoliz, ustekin, risankiz
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4
Q

Mesalamine (5-ASA)

A
  • Not effective in CD (last resort Tx)
  • DI: bleed risk, PPI/H2RA/Antacid
  • Absorped in small intestine, not colon
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5
Q

Golimumab (Simponi)

A

UC
- TNF-i
- SQ q4week

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6
Q

Mod-Severe CD

A
  • acute Tx with PO Pred
  • 1st: Inflix +/- AZA
  • 2nd: Adalimu +/- AZA
  • 3rd: Vedo, Ustekin, Risankiz, or Upadacit
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7
Q

Leflunomide

A
  • Needs loading dose (PO QD)
  • AE: Teratogenic, inc LFTs, rash, D
  • Monitor: CBC, SCr, LFts
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8
Q

Abatacept (Orencia)

A

RA
- T-cell-i/co-stimulation modulator
- IV q4week +/- MTX
- if failed other DMARD
- caution in COPD pts

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9
Q

Mild-Mod CD

A
  • Budesonide CR x8-16w (if distal or right-sided)
  • Sulfa and Mesa not effective
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10
Q

Tocilizumab (Actrema)

A

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

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11
Q

Sarilumab (Kevzara)

A

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)

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12
Q

Natalizumab

A

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

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13
Q

Upadacitinib (Rinvoq)

A

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

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14
Q

Rituximab

A

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

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15
Q

Sulfalazine (IBD)

A
  • Monitor: CBC, LFTs
  • DI: NSAIDs/Anticoags
  • AE: HA
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16
Q

Corticosteroids (IBD)

A
  • Remission only and flare ups
  • PO Pred
  • CR budesonide
  • IV Methylprednisolone
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17
Q

Risankizumab (Skyrizi)

A

UC and CD
- Selective IL-23 antagonist
- Hepatotoxic/ inc in LFT
- possible inc in lipids
- IV then SQ

18
Q

Mild-Mod UC

A
  • Extensive: oral mesalamine
  • Left sided: topical mesa enema
  • Proctitis: suppository
  • CR Budesonide (x8-16w) or PO Pred
  • Combo oral + topical best for left/extensive
19
Q

Biologics AE/Monitoring

A
  • ADR: infection risk, malignancy risk (lymphoma), HSTCL, CHF exacerbations, hepatoxicity
  • Monitor: CXR, Hep B/C, CBC, LFTs, Lytes, CRP, TDM
20
Q

Ustekinumab (Stelara)

A

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

21
Q

RA Adjunct

A
  • never MonoTx
  • NSAIDs or Corticosteroids
  • Celecoxib CI’d in sulfa Ax
  • use corticosteroids for shortest time as possible
22
Q

Anakinra

A

RA
- IL-1-i
SQ QD +/- MTX
- if failed other DMARD
- if CrCl<30–> SQ every other day
- AE: dec neutrophils (monitor)

23
Q

Methotrexate (RA)

A

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

24
Q

Mod-Severe UC

A

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

25
Q

Methotrexate (MTX)

A

CD ONLY, SQ/IM qWEEK
- AE: bone marrow suppression (1 mg FA), NVD, TERATOGENIC
- CI: pregnancy, liver disease, CrCl <40
- Monitor: CBC, SCr, LFT

26
Q

Vedolizumab (Entyvio)

A

UC and CD
- inhibits leukocyte migration (anti-integrin (gut specific))
- preferred for UC induction
- PML not observed
- combo w/ AZA/6-MP

27
Q

RA TNF-i

A
  • Etanercept
  • Inflix w/ MTX
  • Adalimu +/- MTX (if inadequate response)
  • Golimumab w/ MTX
  • Certolizumab +/- MTX
    (only Inflix is IV)
28
Q

UC Maintenance of Remission

A
  • Mesa, Inflix, Adalimu, AZA, or 6-MP
  • OR Vedoliz, Ustek, Mirik, Risanki, Upadacit, Tofacit, Ozani, Estrasimod
29
Q

Infliximab (Remicade) (IBD)

A

UC and CD
- TNF-i
- Induction and Mx

30
Q

Cyclosporin

A

UC ONLY
- induce reemission in refractory severe UC (bridge Tx)
- AE: Nephrotoxic, Neurotoxic, HTN, inc lipids
- Monitor: BP, BUN/Scr, LFTs

31
Q

Ozanimod (Zeposia) &
Estrasimod (Velsipity)

A

UC
- SP1-i (oral)
- AE: similar to biologics, PML risk, brady/AV delays, inc LFTs, inc BP, resp effect, macular edema
- poss RPLS, PRES
- DI: adrenergic/serotonergic drugs, foods with Tyramine
- CI: pts whoin last 6 mo had MI,
SA block, stroke, TIA,
severe HF, untreated sleep apnea, on MAO-i
- Monitor: BP, spirometry, ECG, optho

32
Q

Severe-Fulminant CD

A
  • inpt IV methylpred –> PO Pred
  • Infliximab preferred, but can use other biologics
33
Q

Tofacitinib (Xeljanz)

A

UC
- JAK-i
- ONLY if pt had inadequate response/intolerant to TNF-i
- AE: similar to biologics, Neutropenia, hypersensitivity
- BLACK BOX: inc mortality, CV events, clots, malignancies if CV risk
- Monitor: lipids, skin
- D/C after 16 weeks if inadequate response

34
Q

Sulfasalazine

A
  • AE: NVD, rash, photosensitivity, leukopenia, thrombocytopenia
  • CI: sulfa Ax
  • Monitor: CBC, SCr, LFTs
35
Q

Corticosteroids Long/Short Term AE’s

A
  • Short: Hyperglycemia, Gastritis, Mood changes, inc BP
  • Long: Aseptic necrosis, cataracts, obesity, growth failure, osteoporosis (give Ca, Vit D, and maybe Bisphos)
36
Q

Mirikizumab (Omvoh)

A

UC
- IL-23p19 antagonist
- Hepatotoxic/ inc in LFT
- IV then SQ

37
Q

Hydroxychloroquine

A
  • not the most effective
  • AE: retinal toxicity, NVD, dermatologic
  • Monitor: Vision exam yearly
  • NO myelosuppression, hepatic, or renal toxicities
38
Q

Certolizumab (Cimzia)

A

CD
- TNF-i
- SQ q4week

39
Q

Adalimumab (Humira) (IBD)

A

UC and CD
- TNF-i
- induction and Mx

40
Q

Azathioprine (AZA) + Mercaptopurine (6-MP)

A

AZA is prodrug converted (TPMT) to 6-MP
- ADR: NVD, bone marrow suppression, pancreatitis
- Monitor: TPMT, CBC, LFTs

DRUGS (35 decks)

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