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Systemic steroids and autoimmune disorders > notes > Flashcards

notes Flashcards

1
Q

What endogenous steroid does fludrocortisone mimic?

A

aldosterone

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2
Q

what kind of activity does fludrocortisone have?

A

mineralocorticoid that balances water and electrolytes which keeps BP stable

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3
Q

fludrocorticoid is FDA approved for what?

A

Addison’s disease

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4
Q

what activity do other steroids like prednisone have?

A

glucocorticoid that is mostly anti-inflammatory

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5
Q

what is cushing’s syndrome?

A

it is the excess of cortisol production either from the adrenal gland production or high doses of exogenous steroids

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6
Q

what is the suppression of the hypothalamus-pituitary-adrenal axis (HPA)?

A

high doses of steroid can cause the adrenal gland to stop producing cortisol by feedback inhibition by suppression of the HPA axis

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7
Q

What is Addison’s disease?

A

when the adrenal gland is not producing enough cortisol

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8
Q

When stopping steroids, they must be tapered off, why?

A

to give time for adrenal glands to start producing cortisol

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9
Q

list glucocorticoids from least to most potent

A

cute & hot pharmacists & physicians marry together & deliver babies

cortisone 25
hydrocortisone 20
prednisone 5
prednisolone 5
methylprednisolone 4
triamcinolone 4
dexamethasone 0.75
betamethasone 0.6
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10
Q

dexamethasone brand

A

DexaPak 6, 10, 13 day

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11
Q

methylprednisolone brand

A 
Medrol
Medrol Therapy Pack
A-Methapred
SOLU-medrol Pack
DEPO-medrol
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12
Q

prednisone brand

A

Prednisone Intensol

Deltasone

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13
Q

prednisolone brand

A

Millipred
Orapred ODT
Pediapred

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14
Q

Triamcinolone brand

A

Kenalog

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15
Q

When should steroids be taken to mimic the natural diurnal cortisol release?

A

between 7-8am

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16
Q

short term SE <1 month of glucocorticoids

A 
mood lability
insomnia
indigestion
bitter taste
hyperglycemia
hypertension
increased appetite/ weight gain
fluid retention
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17
Q

long term SE > 1 month

A

increased intraocular pressure
cushing-like symptoms (moon facies, buffalo hump, muscle wasting, weak bones, striae, acne, GI bleed, esophagitis, hypothyroidism, impaired wound healing, hirsutism, irregular menstruation)

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18
Q

what dose of prednisone constitutes as immunosuppressed?

A

> =2mg/kg/day or >=20mg/day of prednisone/prednisone equivalent for >2 weeks

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19
Q

How many days taper is the Medrol Therapy Pak?

A

6 days

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20
Q

What are the common symptoms of autoimmune disease?

A

fatigue, weakness, pain

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21
Q

strong immunosuppressants can reactivate what diseases?

A

Tb

hep B & C

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22
Q

What are main differences b/w RA and OA?

A

RA is bilateral and symmetrical

OA does not cause “prolonged stiffness”

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23
Q

What are some symptoms of RA?

A

bone deformity
pain
stiffness
joint swelling

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24
Q

which laboratory tests assist in RA diagnosis

A 
anti-citrulinated peptide Ab (ACPA)
rheumatoid factor (RF) - less specific
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25
Q

when should pts w/ RA be initiated on a DMARD?

A

when symptomatic regardless of disease severity

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26
Q

What is the RA txt goal?

A

disease remission or low disease activity

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27
Q

What is the preferred initial therapy for RA pts?

A

methotrexate

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28
Q

What is the drug treatment regimen for pts with moderate to high disease activity despite MTX (w/ or w/o steroids) ?

A

a combination of DMARDs, TNF inhibitor biologic or non-TNF biologic, w/ or w/o MTX

Do not use two biologic DMARDs in combination b/c of fatal risk of infection

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29
Q

What options are there for bridging to wait for DMARDs to take effect in RA?

A

low dose steroids (<10mg/day)

high dose NSAIDs

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30
Q

methotrexate brands

A

Trexall
Otrexup
Xatmap
Rasuvo

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31
Q

BW methotrexate

A

pregnancy
hepatotoxicity
mucositis/stomatitis
myelosuppression

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32
Q

CI methotrexate

A

pregnancy

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33
Q

SE methotrexate

A 
alopecia
photosensitivity
N/V/D
increasing LFTs
stomatitis
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34
Q

When can folate be given when on methotrexate?

A

5mg PO weekly on the day following MTX

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35
Q

hydroxychloroquine brand

A

Plaquenil

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36
Q

warning Plaquenil

A

irreversible retinopathy and loss of vision acuity

caution in pts w/ G6PD deficiency

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37
Q

SE Plaquenil

A

N/V/D, abdominal pain, vision changes (dose-related), skin & hair color changes (rare), rash, pruritus, HA

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38
Q

What should be monitored in pts on Plaquenil?

A

eye exams

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39
Q

sulfasalazine brand

A

Azulfidine

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40
Q

warning sulfasalazine

A

caution in pts w/ G6PD deficiency

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41
Q

CI sulfasalazine

A

allergy to sulfa or salicylate

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42
Q

SE sulfasalazine

A

rash, HA, yellow-orange skin/urine

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43
Q

What should be given in addition to sulfasalazine and why?

A

folate 1mg/day

decreased folate absorption on sulfasalazine

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44
Q

leflunomide brand

A

Arava

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45
Q

warnings leflunomide

A

fetal-embryo toxicity

hepatotoxicity

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46
Q

CI leflunomide

A

hepatic impairment and pregnancy

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47
Q

What needs to be tested and how before using leflunomide?

A

must have negative pregnancy test and use 2 forms of birth control while on medication

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48
Q

how long does a pt have to wait to be pregnant after taking leflunomide?

A

2 years OR do an accelerated drug elimination procedure of cholestyramine or activated charcoal x 11 days

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49
Q

tofacitinib brand

A

Xeljanz

Xeljanz XR

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50
Q

what should Xeljanz not be used with?

A

do not use in combination w/ other biologic DMARDs

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51
Q

MOA tofacitinib

A

JAK enzymes inhibitor which stimulates immune cells

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52
Q

pharmacokinetics Xeljanz

A 
avoid 3A4 inhibitors, inducers
2C19 inhibitor (IR only)
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53
Q

dose adjust Xeljanz

A

dose adjust IR only in moderate renal ior hepatic impairment

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54
Q

which pts should Xeljanz not be initiated?

A

ANC <1000
lymphocyte count < 500
Hgb < 9

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55
Q

DDI methotrexate

A

alcohol, increased hepatotoxicity

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56
Q

what is another name for anti-TNF biologics?

A

TNF-alpha inhibitors

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57
Q

Each anti-tNF inhibitor has its own what type of registry

A

pregnancy registry b/c of unknown risks to the fetus

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58
Q

which anti-tnf biologic DMARDs are available as IV?

A

infliximab (Remicade)

golimumab (Simponi Aria)

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59
Q

Which anti-TNF biologic DMARDs are available SC?

A

adalimumab (Humira)
etanercept (Enbrel)
golimumab (Simponi)
certolizumab pegol (Cinzia)

60
Q

How often is etanercept administered?

A

once weekly SC

61
Q

which anti-TNF inhibitor DMARDs require a filter and why?

A

infliximab (Remicade)

golimumab (Simponi Aria)

62
Q

which anti-TNF inhibitor DMARD causes a infusion reaction?

A

infliximab (Remicade)

63
Q

which anti-TNF inhibitor DMARD causes delayed hypersensitivity reaction? how far later?

A

infliximab (Remicade)

3-12 days after infusion

64
Q

infliximab is compatibile with which solvent only?

A

NS only

65
Q

BW for anti-TNF inhibitors?

A

serious infections, malignancies

66
Q

CI infliximab

A

> 5mg/kg dose in mod-sev HF

67
Q

CI etanecept

A

sepsis

68
Q

CI in anti-TNF inhibitors

A

active systemic infections

69
Q

warning TNF inhibitors

A

may cause demyelinating disease, HF, hepatotoxicity, serious infections, hep B reactivation, myelosuppression

70
Q

how should TNF inhibitors be stored?

A

refrigerator

Humira and Enbrel can be stored at room temp x 14 days

71
Q

when can anti-TNF biologics be used as initial therapy?

A

in severe disease presentation

72
Q

where can Humira be injected?

A

SC in thigh, abdomen

73
Q

where can Enbrel and Simponi be injected?

A

SC thigh, abdomen, upper arm

74
Q

how is rituximab administered?

A

IV

75
Q

MOA of rituximab

A

depletes CD20 B cells

76
Q

warning rituximab

A

reactivation of hep B and C

infusion-elated reactions (premedicate w/ steroid, acetaminophen , anti-histamine)

77
Q

anakinra brand

A

Kinemet

78
Q

warnings anakinra

A

serious infection, malignancy, Tb reactivation

79
Q

when is anakinra used?

A

reserved for after one or two DMARD failure

80
Q

abatacept brand

A

Orencia

81
Q

warning abatacept

A

serious infection
malignancy
Tb reactivation
COPD worseninig

82
Q

what solvent is abatacept stable in?

A

NS only

83
Q

tocilizumab brand

A

Actemra

84
Q

when should Actemra not be used?

A

ANC < 2000, AST or ALT >1.5x ULN, platelets < 100,000

85
Q

when should Kevzara not be used?

A

ANC < 2000, AST or ALT >1.5x ULN, platelets < 150,000

86
Q

Kevzara generic

A

sarilumab

87
Q

classic symptoms of SLE?

A

depression, fatigue, anorexia, weight loss, malar rash, muscle pain, photosensitivity

88
Q

which manifestations of SLE lead to morbidity/mortality?

A

hematologic, neurologic, renal manifestations

arthritis and cutaneous manifestations are most common

89
Q

what % of pts develop lupus nephritis?

A

50%

90
Q

which drugs are most associated with drug-induce lupus erythematosus?

A 
anti-TNF
hydralazine
isoniazid
methimazole
methyldopa
minocycline
procainamide
propylthiouracil
quinidine
terbinafine

Annie Hall Is Merry Merry Mini Pretty Pie & Quite Tubby

91
Q

What agents are used to treat SLE?

how long does it take these agents to work?

which one is the only ones FDA approved for SLE

A

NSAIDS (w/ PPIs), azathioprine, MMF, cyclosporine, cyclophosphamide, hydroxychlooquine, belimumab

6 months to work

belimumab, hydroxychloroquine

92
Q

belimumab brand

A

BeLysta

93
Q

belimumab MOA

A

IgG1 monoclonal antibody - prevent B lymphocyte survival

94
Q

interferon beta agents in MS

A 
Avonex
Plegridy
Betaseron
Rebif
Extavia
Glatiramer acetate (Copaxone, Glatopa)
95
Q

which interferon beta used in MS is pegylated? What is the difference of pegylation?

A

Plegridy

pegylated interferon allows for SC dosing q14 days

other agents are parenteral

96
Q

what MS agents are oral?

A

teriflunomide (Aubagio)
dimethyl fumarate (Tecfidera)
fingolimod (Gilenya)

97
Q

what is the dose of glatiramer acetate?

A

20mg daily SC OR 40mg TIW SC (spaced q48 hours)

98
Q

SE glatiramer acetate

A

injection site reactions, pain, flushing, dyspnea, infection, diaphoresis

99
Q

What is the preferred agent in MS patients who are pregnant?

A

glatiramer acetate (Copaxone, Glatopa)

100
Q

MOA glatiramer acetate

A

immune modulator that suppresses T-lymphocytes

101
Q

Which agents for MS are interferon beta-1a?

ROA and frequency?

A

Avonex IM weekly

Rebif SC TIW

102
Q

which agents for MS are interferon beta-1b?

ROA and frequency?

A

Extavia SC every other day

Betaseron SC every other day

103
Q

which agent for MS is peginterferon beta-1a?

ROA and frequency?

A

Plegridy SC q14 days

104
Q

MOA of interferon beta products

A

enhances immune function by altering surface antigens

105
Q

warnings interferon beta priducts

A

psychiatric disorders, increasing LFTs, injection site necrosis, thyroid disorders (hypo, hyper)

106
Q

SE interferon beta products

A

flu-like symptoms (may premedicate)

107
Q

which interferon beta products can be left at room temperature?

A

Betaseron

Extavia

108
Q

which interferon beta products should not be shaken?

A

Avonex, Betaseron, Extavia

109
Q

If refrigerated, what should you do with interferon beta products before injection?

A

bring to room temperature and DO NOT take out air bubbles b/c will lead to loss of medication

110
Q

which oral immune modulator is contraindicated in pregnancy and severe hepatic impairment?

A

teriflunomide (Gilenya)

111
Q

which oral immune modulator causes bradycardia?

How should the pt be monitored?

A

fingolimod (Aubagio)

monitor for 6 hours after initial administration
ECG baseline and after monitoring period

112
Q

which immune modulator is contraindicated in pts w/ hx of CVD or stroke?

A

fingolimod (Aubagio)

113
Q

which immune modulator should not be crushed, chewed, etc?

A

dimethyl fumarate (Tecfidera)

114
Q

SE Aubagio

A

macular edema, hepatotoxicity, myelosuppression

115
Q

which immune modulator should be cautious of in pts on HR lowering meds?

A

fingolimod (Aubagio)

116
Q

which agent is a potassium channel blocker used in MS? What is it for?

A

dalfampiridine (Ampyra)

increase nerve conduction for walking

117
Q

Ampyra contrauindication

A

hx of seizures

118
Q

How long does it take for Ampyra to work?

A

6 weeks, most pts do not respond

119
Q

What is the mAb that binds to the alpha-4 subunit of integrins on surface of leukocytes used in MS?

A

natalizumab (Tysabri)

120
Q

which agent is a CD52 directed cytolytic mAb?

A

alemtuzumab (Letrada)

121
Q

which agent targets CD20+ B cells?

A

ocrelizumab (Ocrevus)

122
Q

which agent is an IL-2 antagonist?

A

daclizumab (Zinbryta)

123
Q

which recombinant humanized mAb used in MS are IV?

A

Ocrevus and Letrada

124
Q

CI Lemtrada

A

HIV pts because prolonged decrease in CD4 count

125
Q

CI Zinbryta

A

hepatic disease

126
Q

CI Ocrevus

A

active HepB disease

127
Q

which recombinant humanized mAb used in MS require a REMs program? why?

A

Lemtrada, Zinbryta

serious, fatal autoimmune conditions, infections, malignancies

Zinbryta can cause autoimmune hepatitis

128
Q

how do you monitor patients on daclizumab

A

LFTs at baseline, monthly for 6 months after last dose

129
Q

When are recombinant humanized mAb indicated in MS?

A

after failure with 2 or more MS agents

130
Q

what is the presentation of Raynaud’s phenomenon?

A

the fingertips turn white ten blue. Once it warms, it becomes red and swollen

131
Q

What is the preferred agent used in Raynaud’s?

A

CCB - nifedipine

132
Q

What is celiac disease?

A

It is an immune response to gluten found in wheat, barley and rye

133
Q

What are the common symptoms of celiac disease?

A

abdominal pain, diarrhea, bloating, weight loss

constipation more in children

134
Q

how can pharmacists check to see if excipients are gluten-free?

A

package insert to see if it says it contains starch and if it specified whether or not if its corn, wheat, tapioca or potato. May need to call manufacturer.

135
Q

What can be used to treat dry eye in Sjogren’s syndrome?

A

OTC artificial tears. If they dont work then

cyclosporine (Restasis) or lifitegrast (Xiidra).

136
Q

What is the SE of Restasis

A

burning

137
Q

what is the SE of Xiidra

A

unusual taste

138
Q

dry mouth treatment agents

A

OTC salivary stimulation (xylitol, sugar free gum), antimicrobial mouthwashes, salivary substitutes. If these dont work then muscarinic agonistslike pilocarpine (Salagen) or cevimeline (Evoxac).

139
Q

CI Salagen and Evoxac and why?

A

contraindicated in pts w/ uncontrolled asthma or narrow angle glaucoma b/c of cholinergic effects

140
Q

what kind of agent is glycopyrrolate

A

anticholinergic agent used for excess salivation - check to see if there is inappropriate use causing dry mouth

141
Q

What are the topical agents used to treat psoriasis?

A

tazarotene, anthralin, coal tar, steroids, calcipotriene

142
Q

what is the biggest con of coal tar products?

A

very messy and stains clothes, bedding, etc

143
Q

what are the systemic agents for psoriasis txt?

A

acitetin (Soriatane)

apremilast (Otezla)

144
Q

when is acitretin (Soriatane) used?

A

in severe cases of psoriasis

145
Q

SE of apremilast (Otezla)

A

diarrhea, weight loss

146
Q

what are the IL-RA used in psoriasis txt?

A

ustekinumab (Stelara)
guselkumab (Tremfya)
brodalumab (Siliq)

147
Q

which agents that are used to treat RA, must be given with methotrexate?

A

infliximab (Remicade)
golimumab (Simponi, Simponi Aria)
rituximab (Rituxan)

Systemic steroids and autoimmune disorders (1 decks)

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