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Small Animal Medicine > Immunosuppressive Therapies > Flashcards

Immunosuppressive Therapies Flashcards

1
Q

what are the 6 immunosuppressive drugs used in vet med?

A
  1. glucocorticoids
  2. azathioprine
  3. cyclosporine
  4. chlorambucil
  5. leflunomide
  6. mycophenolate mofetil
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2
Q

what are adjunctive therapies that can be added onto immunosuppressive therapy to help control the disease?

A
  1. human IVIG
  2. vincristine
  3. melatonin

other supportive treatments – blood products, antiplatelet therapy.

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3
Q

what are the 5 criteria to consider when choosing an immunosuppressive therapy?

A
  1. expected course and prognosis of disease
  2. concurrent diseases
  3. safety and efficacy
  4. ease of admin and monitoring
  5. cost
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4
Q

which of the following is FALSE about glucocorticoids?
A. effective
B. slow onset
C. cheap
D. mechanism of action if to quiet the immune system by downregulating inflammatory cytokines etc.

A

B. slow onset

these drugs have a rapid onset

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5
Q

what are the side effects associated with glucocorticoids?

A
  1. PU/PD, polyphagia, panting
  2. muscle atrphy and weakness
  3. iatrogenic cushings
  4. vacuolar hepatopathy (large liver; inc liver enzymes ALKP>ALT)
  5. infection, sepsis
  6. GI ulcers
  7. hypercoagulability
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6
Q

what are contraindications for glucocorticoids?

A
  1. diabetes mellitus
  2. infection
  3. hyperadrenocorticism
  4. NSAID therapy (GI ulceration)
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7
Q

what are the 2 common glucocorticoids used in vet med?

A

prednisone
dexamethasone

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8
Q

when and how should you wean a patient off of glucocorticoids?

A

when there is clinical remission for atleast 2 consecutive weeks (specific signs controlled will depend on the disease), then you can reduce the dose 25% every 2-4 weeks.
This will take 4-6 months.
Discontinue it completeley if possible or go to lowest effective dose.

if the patient relapses, return to the original effective dose.

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9
Q

when should you consider OTHER therapies with a patient currently on glucocorticoids?

A
  1. no-to-poor response
  2. excessive side effects
  3. long-duration therapy anticipated
  4. corticosteroids are contraindicated (diabetes, hyperadrenocorticism, infection, NSAIDs)
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10
Q

What factor limits the use of azathioprine in cats?

A

metabolism ot thiopurine methyltransferase

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11
Q

what are the side effects associated with azathioprine?

A
  • cytopenias
  • hepatotoxicity
  • chronic subclinical anemia (PCV 25-30%; nonregenerative)
  • GI signs (mild and self-limiting)

you should monitor CBC and chemistry

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12
Q

How can you identify azathioprine induced hepatotoxicity?

A

ALT > ALP and increased bilirubin

reduce the dose (can reverse it) or discontinue (if hyperbilirubinemia bc indicates liver failure)

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13
Q

what drug can you add on to azathioprine to protect the liver and prevent/reverse hepatotoxicity?

A

SAM-e (denamarin)

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14
Q

What is the primary use of azathioprine?

A

Used as a 2nd line therapy in cases of IMTP, IMHA, IMPA, IBD, or SLE

used for glucocorticoid-sparing effects

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15
Q

Which of the following is FALSE regarding azathioprine?
A. requires loading dose
B. administered every 24 hours
C. slow onset
D. cheap
E. tapered after prednisone over 2-3 months.

A

B. administered every 24 hours

admin every 48 hrs

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16
Q

which immunosuppressive drug(s) is/are NOT myelosuppressive?

A
  1. glucocorticoids
  2. cyclosporine
17
Q

what is the MOA of cyclosporine?

A

impairs T cell function and blunts the immune response

therefore is NOT myelosuppressive

18
Q

what are the biggest downsides to cyclosporine?

A

LOTS of drug interactions
primarily GI side effects (v/d)
opportunistic infections

others: hepatotoxicity, nephrotoxicity, gingival hyperplasia, hypertrichosis, excessive shedding, papillomatosis, platelet activation

19
Q

what are common conditions that cyclosporine is used to treat?

A

IMHA, ITP, IBD, MG, MUE, GN, anal furunculosis, pemphigus foliaceous

20
Q

what is the onset for cyclosporine?

A

days to months

21
Q

How do we determine doses for cyclosporine in patients?

A

there are chronic inflammatory doses – 5 mg/kg/day, there are acute life-threatening doses 5-10 mg/kg/day
but each patient is different and the dose will likely better be determined by therapeutic drug monitoring.

22
Q

T/F: oil-based cyclosporine is the recommended over water-based because the bioavailability is higher

A

FALSE

microemulsion (atopica) improves bioavailability. The oil-based is NOT recommended because the bioavailability is too variable. Caution with generic versions of this drug.

23
Q

Which of the following is TRUE about chlorambucil (leukeran)?
A. targets B cells and can lead to myelosuppression
B. fast onset (24 hours)
C. nephrotoxicity is most common side effect
D. used more commonly in dogs than cats
E. cheap

A

A. targets B cells and can lead to myelosuppression

it has a slow onset (2 weeks), causes GI side effects, myelosuppression, alopecia/poor hair growth, and neuro signs (in cats). Can cause chronic protein losing enteropathies in dogs.
This drug is used more commonly in cats as a 2nd line therapy for IBD, PLE, and glomerulonephritis
The drug is expensive

24
Q

what are the side effects associated with leflunomide?

A

GI (inappetance, vomiting)
Myelosuppression
cutaneous drug reactions
hepatotoxicity

monitor CBC and chem

25
Q

T/F: you should start patients at a higher dose of leflunomide and then decrease to lowest effective dose similar to prednisone or dexamethasone

A

false – start at a lower dose and increase if needed. this lowers the incidence of side effects.

26
Q

what are the MOST common side effects associated with mycophenolate mofetil?

A

GI – diarrhea, vomiting, hyporexia

also can cause myelosuppression and lymphoma (rare)

monitor CBC/Chem

27
Q

which drugs DECREASE the bioavailability of mycophenolate mofetil?

A

fluoroquinolones
metronidazole
PPIs
glucocorticoids
cyclosporine

28
Q

which drug should NOT be used concurrently with mycophenolate mofetil due to similar MOAs?

A

azathioprine

29
Q

T/F: mycophenolate mofetil can be used as a stand alone drug in stable disease or in combination with prednisone

A

true

30
Q

T/F: mycophenolate mofetil is a more cost-effective immunosuppressive agent to choose for large breed dogs

A

true

31
Q

What is the biggest downside to mycophenolate mofetil?

A

takes 2-3 weeks to work.

32
Q

Vincristine is an adjunctive treatment for which condition?

A

ITP

Small Animal Medicine (15 decks)

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