Lupus EXAM 4 Flashcards
What is Lupus?
Auto-immune disease
-any organ can be affected
How would a patient with Lupus present?
-Skin lesion (most often), rash
-oral and nasal ulcers
-alopecia
-pleuritis, pericarditis (chest bain)
-kidney damage (proteinuria, RBC cast in the blood)
-neurologic (seizures, psychosis, AMS. neuropathy)
-Cytopenias (hemolytic, neutropenia, leukopenia, lymphopenia, thrombocytopenia)
What labs are used to determine Lupus?
-Antinuclear antibody (ANA)
-Anti-double-strand DNA (dsDNA) – present in 60-70% of patients
-Anti-Sm
-Antiphospholipid antibodies
-Lupus anticoagulant
-Anticardiolipin
-Anti-β2-glycoprotein
-Low complement
-Direct Coomb’s test (w/o hemolytic anemia)
Antibodies of Antiphospholipid are antibodies against what?
Lupus anticoagulant
Anticardiolipin
Anti-ß2-glycoprotein
What is the leading cause of death for Lupus?
What is the LDL goal in these patients?
Cardiovascular
-accelerated arteriosclerosis (inflammation causes plaques), pericarditis, myocarditis
LDL goal: <100 mg/dl
What are the possible triggers of Lupus?
Sun
smoking
Obesity
What is the drug class of choice?
What is the supportive care approach?
Immunosuppressants
supportive care:
-immunizations
-manage co-morbidities (HTN, dyslipidemia, depression)
What is the first-line treatment for unspecific Lupus?
-NSAIDs
-hydroxychloroquine (malaria agent)
-Corticosteroirds
2nd line:
-Belimumab
-Mtx
-Mycophenolate mofetil (immunosuppressant)
-Cyclophosphamide
What is the first-line treatment for Lupus nephritis?
hydroxychloroquine
2nd line:
Mycophenolate mofetil + corticosteroid
then MMF + Azathioprine
What is the first-line treatment for neuropsychiatric lupus?
hydroxychloroquine
2nd line:
-Corticosteroids
-Cyclophosphamide
-Azathioprine
+
Anticonvulsatns (for seizrue
Antidepressants (for depression
Antipsychotics (for psychotic conditions)
What is the first-line treatment for cutaneous lupus?
topical corticosteroids
pimecrolimus
tacrolimus
2nd line:
-hydroxychloroquine
-Methotrexate
-Retinoids
-MMF
-Dapsone
-Thalidomide
Last line treatment for Lupus?
-Rituximab
-tacrolimus/cyclosporine
-IVIG
-plasmapheresis (remove the antibodies, then infusion of new antibodies)
Newer Lupus agents
for lupus nephritis
-Voclosporine (Lupkynis®) - calcineurin inhibitor
for SLE
-Anifrolumab (Saphenlo®) - INF type 1 antagonist
the role in therapy is still unclear
What is the brand name and dose of hydroxychloroquine?
Plaquenil
200-400 mg
What are the side effects of hydroxychloroquine?
Retinal toxicity (yearly eye exam)
Cytopenias
What are the short and long-term side effects of corticosteroids?
short-term
-Hyperglycemia
-immunosuppression
-WBC elevation
-fluid retention, HTN
-GI distress, ulcers
long-term
-Bone mineral density loss
-HPA suppression
What are the brand names of prednisone, prednisolone, and methylprednisolone?
prednisone: Deltasone
prednisolone: Medrol
methylprednisolone: Solu-Medrol
Which of the corticosteroids should be used in patients with liver dysfunction? Why?
Prednisolone or methylprednisolone
bc prednisone must be converted in its active form by the liver
Side effects of NSAIDs
-Afferent (glomerulus) vasoconstriction
-GI distress/ulcers
What is the dose of Methotrexate for Lupus?
10 to 25 mg PO weekly
ADE:
-Myelosuppression
-hepatoxicity (w/ chronic use)
-drug interactions (NSAIDs, sulfonamides, etc.)
What is the brand name of azathioprine?
Imuran
Azathioprine is the prodrug of 6-MP
What is the brand name of rituximab?
Rituxan
HBV reactivation and hypersensitivity reactions
How do NSAIDs and Corticosteroids increase the risk for GI ulcers?
decrease in prostaglandin production
prostaglandin provides protection via carbonate and mucus layer
What are the complications of Antiphospholipid Antibody Syndrome?
Venous, arterial microvascular thrombosis (clots)
-fetal loss after 10 weeks, multiple early misscarriage, intrauterine growth restriction, severe eclampsia
-> can be caused by clotting in the placenta
What is the prophylactic treatment for Antiphospholipid Antibody Syndrome (APS)?
How is the treatment goal different for arterial and venous clot prevention?
primary prophylaxis (no clot before)
-hydroxychloroquine + ASA 81 mg
secondary prophylaxis (venous)
-Warfarin INR goal 2-3
secondary prophylaxis (arterial)
-Warfarin goal may be 3-4
(DOACs are less effective)
Which anticoagulant for blood clots is used for patients with lupus who try to conceive?
LMWH (Warfarin is category X)
if they have APS they should use Warfarin and wait with pregnancy plans
Which of the drugs used for lupus are teratogenic?
-Methotrexate
-leflunomide
-Mycophenolate mofetil (MMF)
-cyclophosphamide (cause infertility)
-thalidomid
counsel to use contraceptives in patients in childbearing age !! (progestin-ONLY, since estrogen has thrombotic risk)
What is the max duration recommended for progestin-only contraceptives (Depo-Provera)?
not more than 2 years
-risk for BMD loss
What should be considered in patients during lupus treatment before trying to get pregnant?
no flares for 6 months before conceiving
Which drug helps to prevent preterm preeclampsia?
Aspirin 81 mg
What is the preferred drug for lupus in pregnant patients?
hydroxychloroquine
2nd line:
-Prednisone
-Azathioprine (6-MP is not safe for pregnants, but azathioprine is a prodrug and the fetal liver is not able to activate to convert it)
Which drugs can cause lupus?
Procainamide (antiarrythmic)
High dose of hydralazine (>200 mg)
Which vaccines are recommended for patients with lupus?
-Pneumococcal vaccination recommended
-Yearly influenza
-avoid live-attenuated vaccines (due to immunocompromised state)
