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MyDermatology-Bolognia > PGY-2 Therapeutics > Flashcards

PGY-2 Therapeutics Flashcards

1
Q

1) What is the mechanism of action of oral prednisone? List 5.

A
  1. Inhibits NfKB and AP-1–> transcription factors that stimulate inflammatory cytokine production
  2. Induces apoptosis auto reactive T-cells, eosinophils
  3. Decreases Ig production from B-cells
  4. Inhibits phospolipase A2–> decreases productions prostaglandins, eicosanoids, leukotrienes
  5. Inhibits neutrophil apoptosis and margination and migration
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2
Q

2) List 3 absolute contraindication of oral prednisone.

A

Allergy/hypersensitivity
systemic fungal infection
HSV keratitis

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3
Q

3) List 8 relative contraindication for oral prednisone

A
  • HTN
  • Diabetes
  • CHF
  • Prior psychosis or seere depression
  • Active peptic ulcer disease
  • Active TB, + TB skin test
  • Glaucoma
  • Osteoporosis
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4
Q

4) What are the different route of administration of prednisone?

A

Topical, PO, IM, SC, IM, IV, intranasal, inhaled, ophthalmic

Prednisone only= PO

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4
Q

4) What are the different route of administration of prednisone?

A
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5
Q

5) List 4 drug-drug interactions for prednisone.

A

CYP3A4 inhibitors (increase prednisone):
Macrolides, azole antifungals, OCP

CYP3A4 inducers (decrease prednisone):
Rifampin, cholesytramine, phenytoin and other anti-epileptics

Warfarin-increase or decrease warfarin levels when on pred

Isoniazid-pred may decrease levels isoniazid

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6
Q

6) List 8 non-cutaneous side effects prednisone therapy.

A

Steroids withdrawal syndrome: fatigue, headache, lethargy

Addisonian crisis: hypotension, electrolyte imbalances

Brain: psychosis/depression, psudeotumor cerebri

Eyes: cataracts, glaucoma

GI: PUD, bowel perforation, GERD, fatty liver

Infection risk: OIs

MSK: Osteoporosis, myopathy, AVN, premature growth failure, epiphyseal plate closure

Metabolic: HTN, diabetes, weight gain, fluid retention, hyperglycaemia, hypokalemia, elevated TGs

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7
Q

7) List 10 cutaneous side effects of prednisone therapy.

A

Skin atrophy
Telangiectasias
Hirsutism
Telogen effluvium
Moon like facies/buffalo hump
Purpura
Striae
Non healing wounds
Steroid acne
Cutaneous infections
Acanthosis nigricans
Pustular psoriasis (withdrawal)

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8
Q

8) What investigations would you order for someone on prednisone therapy? Baseline and follow up

A

Baseline:
-BP, weight, height, DEXA scan, ophthalmoscope

Labs:
TBST, CXR, Hep B/C, HIV, strongy
TG, K, HbA1c

Monitoring:
BP, weight, ophthalmoscope

Labs:
K, Glucose, TGs

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9
Q

What do you order for Hep B serology

A

HepB sAg
Anti HB sAb
Anti HB cAb

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10
Q

What is the MOA of methotrexate? List 4.

A
  1. Inhibits DNA synthesis –> Inhibition DHFR and thymidylate synthase
  2. T-cell immune suppression: Decrease T-cell proliferation and migration into tissue
  3. B-cell Immunosuppresion: Decreases antibody responses
  4. Decreases inflammation through increases intracellular adenosine
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11
Q

What are 4 enzymes methotrexate inhibits

A

Dihydrofolate reductase

Thymidylate synthase

AICAR transformylase

Ecto 5’ Nucleotidase

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12
Q

List 3 absolute contraindications to MTX

A

Hypersensitivy/allergy
Pregnancy
Lactation

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13
Q

List 6 relative contraindications for MTX

A

Liver disease
Renal impairment
Immunodeficiency
Blood cell dyscrasia/cytopenias
Alcoholism
Active TB or Hep B/C

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14
Q

List 6 relative contraindications for MTX

A

Liver disease
Renal impairment
Immunodeficiency
Blood cell dyscrasia/cytopenias
Alcoholism
Active TB or Hep B/C

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15
Q

What are the different routes of administration of MTX? List 5

A

PO
SC
IM
IV
Intrathecal
Intra-arterial

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16
Q

List 3 categories of drug-drug interactions for MTX and 3 drugs in each category

A
  1. Increase risk cytopenias through concomitant folate reduction
    -Sulfa drugs (sulfasalinze, sulfamethaxasole, dapsone), trimethoprim
  2. Increase risk hepatoxicity
    -Alcohol, retinoids
  3. Increase MTX levels and toxicities
    NSAIDS, doxy/minocycline, dipyramidole, furosemide
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17
Q

6) How long do men and women have to be off of MTX before conceiving?

A
  • Women 1 ovulatory cycle
    -Men 3 months
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18
Q

List 6 non cutaneous side effects MTX

A

Infection-OI’s like pneumocystis
Malignancy-increase risk lymphoma +KC
Pregnancy-teratogen
GI-N/V/Diarrhea/oral ulcers/anorexia
Lung-pneumonitis and pulmonary fibrosis
Liver-hepatitis and fibrosis/cirrhosis
Cytopenias

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19
Q

List 6 cutaneous side effects of MTX therapy

A
  • Oral ulcers
  • Alopecia
  • Radiation or sunburn recall
  • acral erythema
  • papular eruption
  • vasculitis
  • cutaneous ulceration or epidermal necrosis
  • Increased risk keratinocyte carcinomas
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20
Q

9) What investigations would you order for someone on MTX therapy?
a) at Baseline
b) Regular monitoring

A

Baseline:
Hep B/C, HIV, tbst, CXR
Cr/urea, LE, LFTs, CBC with differential

Monitoring:

Cr/urea, LE, LFT, CBC with diff

Liver biopsy at 3.5-4 grams cumulative dose (or 1.5 grams if high risk) and at each 1.5 gram interval subsequently, or consider Fibroscan yearly after 1 year of treatment

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21
Q

What is the mechanism of action of Azathioprine (AZT)? List 4

A
  1. Purine synthesis inhibitor/decreased cell proliferation : 6MP–> 6-TG via HGPRT–> purine analog.
  2. T-cell function reduced
  3. Decreases Ab production
  4. Impairs antigen presenting cell function
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22
Q

Which 3 enzymes metabolize 6-Mercaptopurine?

A

Xathine oxidsase
TPMT-thiopurine methyltrasnferase
HGPRT (hypoxanthine guanine phosphoribosyl)

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23
Q

) List 3 absolute contraindication of AZT.

A

Pregnancy
Hypersensitivity
homozygous mutant TPMPT/no TPMT activity

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24
Q

List 4 relative contraindications to AZT

A
  • Active infection: Active Tb or Hep B/C
  • PAncytopenia
  • Prior use alkylating agents
  • Concomitant use allopurinol/febuxostat
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25
Q

What is the dosing for AZT?

A

Homozygous wild type TPMT (15-26): 2-2.5 mg/kg
Heterozygous wild type (6.3-15): 1 mg/kg
Hetero mutant (<6.3): Do not use

*2-4 for pemphigus

*Mufti says unless homo normal won’t use it at all

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26
Q

8 adverse events Azathioprine

A

a. Teratogenic
b. Increased risk opportunistic infections (HSV, scabies, HPV)
c. TB, Hep B, JC virus reactivation
d. Hepatotoxicity and hepatic vein occlusion
e. Hypersensitivity reaction
f. GI: nausea, vomiting, diarrhea, pancreatitis
g. Cytopenia
h. Malignancy: Increased risk lymphoma and SCC

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27
Q

Can a patient taking AZT take the following medications (provide reasoning if not)?
-Allopurinol
-Febuxostat
-ACEi
-TMP-SMX

A

No for all of them.
For allopurinol/febuxostat–> can technically take but need to dose reduce. Inhibit XO= increase through HGPRT pathway=increase levels 6-TG and bone marrow suppression

ACEi-increaase risk leukopenia
TMP-SMX-concmitant folate inhibitor, increase toxicity

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28
Q

List 10 derm related indications for AZT (on or off-label); ii) what is the FDA indication for AZT?

A

FDA indication: Organ transplant, RA
Derm:
i. Immunobullous diseases: PV, BP, Cicatricial pemphigoid
ii. Vasculitis conditions: PAN, LCV, GPA, EGPA, urticarial vasculitis
iii. Photodermatoses: Actinic dermatitis, PMLE
iv. Neutrophilic dermatoses: Behcets, PG
v. AI-CTD: SLE, DLE, DM, relapsing polychonditis, eosinophilic fasciitis
vi. Dermatitis/Papulosquamous: Contact dermatitis, atopic dermatitis, hand dermatitis, PsO/PsA, LP
vii. Others: Sarcoid, EM, vitiligo, GVHD, leprosy

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29
Q

What investigations would you order for someone on AZT therapy? Baseline and monitoring

A

Baseline:
Hep B (sAG, sAB, core Ab), Hep C Ab, HIV, TBSR and CXR
CBC, liver, kidney
UA
Pregnancy
TPMT level

Monitoring:
i. CBC with differential
ii. LFTs including AST/ALT

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30
Q

1Write a prescription for someone who will be starting AZT for the very first time. Indication is pemphigus vulgaris and the patient has no comorbidities.

A

Azathioprine 50 mg po daily. M: 4 weeks, no refills

Increase to 100 or 150 mg daily

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31
Q

What are 2 formulations of cyclosporine? What is the difference in their dosage and bioavailability

A

Neoral: microemulsion, more bioavailable due to better absorption
Dose: 2.5-4 mg/kg 10-50

Sandimmune: 2.5-5 mg/kg
-30%

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32
Q

NAme 3 MOA of cyclosporine

A

a. Completes with cyclophilin to inhibit calcineurin which inhibits NFAT-1 transcription factors which down regulates IL-2 production which decreases T-cell production
b. Inhibits IFN-Y production by T-lymphocytes reduced keratinocyte proliferation and HLA-DR positivity
c. Binds to receptor associated heat shock protein 56 inhibits transcription of proinflammatory cytokines such as GM-CSF, IL-3, 4, 5, 6, 8, TNF-alpha

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33
Q

5 absolute contraindications to CsA

A
  1. Renal dysfunction-severe
  2. Uncontrolled HTN
  3. Allergy/hypersensitivity
  4. Active infection
  5. Persistent malignancy
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34
Q

8 relative contraindicatons to CsA

A

Concomitant:
-puva
-radiation
-bosentan
-immunosuppresant

Malignancy (clinically cured or persistent) except NMSC (product monograph)

Immune deficiency

Pregnancy/lactation

Drugs that interact with CsA or nephrotoxic

Unreliable patient

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35
Q

How is cyclosporine metabolized (which enzyme? Organ?) and excreted? What is its half-life?

A

Metabolized in liver, excreted in bile, half-life 5-18 hours

CYP 3A4

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36
Q

List 8 adverse effects of cyclosporine.

A

a. HTN
b. Renal impairment
c. Increased risk malignancy
d. Increased risk infection
e. GI: Nausea, vomiting, abdominal pain
f. Hepatotoxicity
g. MSK: Myalgia, lethargy
h. Neuro: tremor, headache, paresthesia, hyperesthesia
i. Cutaneous: see b
j. Hyperlipidemia

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37
Q

7) List 4 lab abnormalities that can be see with cyclosporine.

A

a. Hyperkalemia, hyperuricemia, hypomagnesia, hyperglycemia, hyperlipidemia

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38
Q

8) List 5 mucocutaneous side effects of cyclosporine.

A

a. Hypertrichosis
b. Gingival hyperplasia
c. Acne
d. Hirsutism
e. Alopecia
f. Keratosis pilaris
g. Sebaceous hyperplasia
h. Infections
i. Trichodysplasia spinulosa
j. Epidermoid cysts
k. Increased risk keratinocyte carcinoma

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39
Q

9) List 7 derm related indications for Cyclosporine (on or off-label)

What is the FDA derm indication for CsA

A

FDA: Psoriasis- SEVERE, RECALCITRANT, FAILED OTHERS-MAX 1 YR

Others:
AD
CSU
PG
BP
PV
PRP
LP
SJS/TEN
AI-CTD-lupus, DM

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40
Q

10) What investigations would you order for someone on Cyclosporine therapy

A
  • BP x 2
  • CBC + diff, LFT, Cr x 2, BUN, urinalysis
  • Mg, K, uric acid, fasting lipid profile
  • consider Ca2+, Tbili, HBV/HCV, HIV, U/A w Alb:Cr ratio, CXR + TB skin test/IGRA
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41
Q

Monitoring ix for CsA

A

i. BP measurement qvisit
ii. Cr, BUN, UA
iii. CBC, LE/LFTs
iv. Lipid profile
v. Mg, K, Uric acid

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42
Q

11) List 3 medications which interact with cyclosporine and lead to the following:
a. Increased toxicity (CYP3A4 inhibitors)

A

Azoles
Macrolides
CCB-diltiazem/verapamil
GRaprefruit juice

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43
Q

3 medications that lead to decreased efficacy of CsA

A

Carbamazepine
Phenytotin
Rifampin

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44
Q

3 medications that increase risk nephrotoxicity in CsA

A

NSAIDS
Aminoglycosides
Ampho B

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45
Q

1) List 4 benefits of using sunscreens

A

a. Carcinogensis prevention
b. Sunburn prevention
c. Photoaging prevention
d. Photoimmunologic suppression prevention
e. Prevent flares of photo dermatoses (e.g. PMLE, SLE, DM, etc.)

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46
Q

How is SPF calculated

A

ratio of duration of UV radiation exposure required to produce the minimal erythema dose (MED) in sunscreen-protected skin vs unprotected

*UVB

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47
Q

What is the CW

A

the wavelength below which 90% of the area under the absorbance curve resides.

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48
Q

What is the CW

A

The CW for a particular product is the wavelength at which the cumulative absorption of radiation above 290 nm is 90%.

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49
Q

What does broad spectrum refer to

A

Broad spectrum refers to a sunscreen for which the critical wavelength is 370 or above. It protects against UVB and UVA.

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50
Q

What is the mechanism of action of physical and chemical sunscreen agents?

A

a. Physical: Mostly reflect/scatter UV light, but also may absorb photons (especially micronized versions)
b. Chemical: Absorbs photons of UV light

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51
Q

List 5 UVB absorbers.

A

a. PABA and derivatives: PABA, padimate O
b. Cinnamates: Octinoxate, Cinoxate
c. Salicylates: Homosalate, Octisalate
d. Octocrylene
e. Ensulizole

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52
Q

List 5 UVA absorbers.

A

UVA “BEAMBS”

Bemotrizonol (Tinosorb S)
Ecamsule/Mexoryl SX
Avobenzone
Menthyl anthranilate (Meradimate)
Bisdizulizole/ Neo heliopan AP

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52
Q

List 4 UVA + UVB absorbers

A

BODI
–> UVA+B best for yuour BODI
A+ B= ZEE Best coverage
a. Oxybenzone and dioxybenzone (Benzopheone 3 and 8)
b. Iscotrizonol (Uvasorb HEB)
c. Drometrizole trisiloxane (Mexoryl XL)
d. Bisoctrizole (Tinosorb M)

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53
Q

What is helioplex

A

Avobenzone + Oxybenzone

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54
Q

List 3 physical sunscreens

A

a. Titanium dioxide
b. Zinc oxide
c. Iron oxides
d. Ferrous oxide

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55
Q

10) List 3 contraindications to using sunscreens.

A
  • Known sensitivity to sunscreen or vehicle
  • Kids < 6 mos of age
  • As a sole component of photoprotection
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56
Q

1) What are the two broad categories of anesthetics?

A

Amides
Esters

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57
Q

Differentiate how esters and amides are metabolized (be specific) and list contraindications for each.

A

Amides:
CYP3A4 in liver

Contraindications: end stage liver dz

Esters:
Psuedocholinesterase, exerted by renal

Contraindications: psuedocholinesterase deficiency, renal insufficiency, PABA allergy

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58
Q

3) List 5 amide anesthetics. List 2-3 important points for each (if available).

A

Lidocaine/xylocaine -fastest onset, #1 preggo choice

Marcaine/Bupivicaine- longest duration w/ epi, highest risk cardiac toxicity, risk fetal Brady

“PREM”
Prilocaine

Ropivicaine- longest duration action w/out episode

Etidocaine

Mepivicaine

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59
Q

4) List 3 ester anesthetics.

A

Procaine/novocaine

CHLOprocaine

Tetracaine

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60
Q

5) What is the maximum safe dose of lidocaine: i) with epinephrine; ii) without epinephrine; iii) tumescent.

A

with epi: 7 mg/kg
w/out epi: 4.5 mg/kg
Tumescent: 55mg/kg

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61
Q

6) What is the advantages, disadvantages and contraindications of using epinephrine as an additive in local anesthetics?

A

a. Advantages: Safer (more localized/less systemic absorption), longer duration, decreased bleeding, can use more
b. Disadvantages: Decreased uterine blood flow
c. Contraindications: pheochromocytoma, uncontrolled hyperthyroid

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62
Q

What is the advantages, disadvantages and contraindications of using sodium bicarbonate as an additive in local anesthetics

A

a. Advantages: Increased speed onset, decreased pain
b. Disadvantage’s: shorter shelf life ~1 weeks
c. Contraindications: none?

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63
Q

8) List 8 injections techniques that can be used to decrease pain for patients.

A

a. Buffer with bicarb
b. Small diameter needle-30 gauge
c. Warm to room temp
d. Mildly irritate surrounding skin
e. Inject slow into deep subQ, then more superficially as retract
f. Inject in previously anesthetized area then fan out
g. Pre-treat topical anesthetics
h. Slow injection
i. Distraction

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64
Q

9) List 3 reactions that can occur when a patient is injected with an anesthetic. How are heart rate and blood pressure affected in each? Briefly discuss how to manage each.

A

1- vasovagal -HR and BP down–> trendelenburg and cool compress
2-anaphylaxis - HR up, BP down –>
Management: Stop injecting, SC epinephrine 1:1000 0.3 mL, anti-histamines, steroids, oxygen, airway support

3-anesthetic OD- HR down, BP down
-Management: Reassurance, phentolamine, propranolol

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65
Q

10) Discuss the signs and symptoms of lidocaine overdose, management and affect on vitals for the following ranges:
1-6 mc/mlg
6-9
9-12
>12

A

a. i) 1-6 mcg/ml: Circumoral numbness, digital paresthesias, metallic taste, talkative, euphoria, light-headed,
b. ii) 6-9 mcg/ml: Nausea, vomiting, muscle twitching, tremors, blurred vision, slurred speech, tinnitus, excitement, psychosis
c. iii) 9-12 mcg/ml: seizures, cardiopulmonary depression
d. iv) >12 mcg/ml: coma, cardiopulmary arrest

> 12 coma and cardiopulmonary arrest

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66
Q

What is the mechanism of action of vismodegib?

A

SMO (smoothened receptor) inhibitor–> Prevents activation of transcription factors GLI

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67
Q

What is vismodegib used for?

A

a. Adults with
-metastatic basal cell carcinoma,
-with locally advanced basal cell carcinoma that has recurred following surgery
-who are not candidates for surgery and who are not candidates for radiation.

-gorlins off label

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68
Q

3) List 5 side effects for vismodegib. Which is the most common?

A

a. Muscle spasms #1
b. Alopecia #2
c. Dysgeusia #3
d. Weight loss, anorexia
e. Fatigue
f. Vomiting/diarrhea/abdominal pain
g. Headache
h. Arthralgia
i. Pruritus
j. delayed wound healing in select patients

How well did you know this?
1
Not at all
2
3
4
5
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69
Q

List 2 BRAF inhibitors.

A

Vemurafenib
Dabrafenib
encorafenib

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70
Q

What is the MOA of BRAF inhibitors

A

a. BRAF is a serine-threonine kinase in MAPK pathway, important for cell division. BRAF inhibitors target the BRAF V600E mutation and interfere with the MAPK signalling pathway

71
Q

List 5 side effects associated with BRAF inhibitors

A

Cutaneous: Keratotic lesions (verrucous keratoses, KA, SCC), papulopustular exanthem, photosensitivity, plantar hyperkeratosis, alopecia,

Arthralgia
Nausea
Fatigue
Diarrhea
QT prolongation
Retinal vein thrombosis
Palmar plantar erythrodysesthesia

72
Q

List 2 MEK inhibitors.

A

Trametinib
Cobimetinib

73
Q

What is the MOA of MEK inhibitors?

A

a. Inhibit MEK1/2 in the MAPK pathway

74
Q

Name 5 side effects of MEK inhibitors

What are 2 serious side effects

A

GI most common -diarrhea, N/V
Hypoalbuminemia
Dysguesia
Xerostomia
Fever, chills

Fever, ILD, cardiomyopathy, retinal vein occlusion, retinal pigment epithelium detachment, serious skin rash (rash, acneiform dermatitis, palmar plantar erythrodysesthsia)

75
Q

Give an example of a CTLA-4 inhibitor.

A

Ipilimumab

76
Q

What is the MOA of CTLA-4 inhibitors?

A

IPiliumab prevent the inhibitory binding reaction of CTLA-4 on T-cells with B7 antigen on APCs in the lymph node, thereby allowing the new T-cell to become activated

77
Q

List 5 side effects of CTLA-4 inhibitors. What is the most common and which is the most severe?

A

a. Skin
i. Rash (most common)-eczematous or maculopapular
ii. Alopecia
iii. Pruritus
iv. Hypopigmentation

b. GI
i. Diarrhea, constipation, bloating
ii. Colitis–> most life threatening
c. Hypothyroid, hypopituitarism
d. Transaminitis, hepatitis

78
Q

List 2 PD-1 inhibitors

A

Pembrolizumab
Cemiplimab
NNivolumab

79
Q

List 3 PDL-1 inhibitors:

A

Atezolizumab
Avelumab
Durvalumab

80
Q

What is the MOA of PD-1 inhibitors?

A

PD-1 is an immune checkpoint inhibitor expressed by activated T-cells, puts brake on immune system. Binds to PDL-1 or PDL-2 on tumor cels, inactivated T-cells. PD-1 inhibitors prevent T-cell deactivation = increased immune mediated tumoricidal

81
Q

List 5 side effects of PD-1 inhibitors.

A

Fatigue- most common in bold
Cutaneous: Pruritus, Rash

Pneumonitis
Colitis
Hepatitis
Nephritis
Thyroid dysfunction

82
Q

What are the uses for:
BRAF inhibitors
MEK inhibitors
CTLA-4 inhibitors
PD-1 inhibitors:
PD-L1 inhibitors

A

a. BRAF inhibitors: Melanoma
b. MEK inhibitors: Melanoma
c. PD-1 inhibitors: Melanoma, merkel cell carcinoma, BCC and SCC (cemiplimab)
d. PDL-1 inhibitors: Merkel cell carcinoma (Avelumab)
e. CTLA-4 inhibitors: Melanoma

83
Q

List 4 systemic therapies that can be used to treat infantile hemangioma (IH).

A

Propranolol
Prednisone
Vincristine
Rapamycin

84
Q

What baseline investigations would you consider in someone who you would like to treat with propranolol?

A

Cardiac exam, BP/HR, consider EKG

If PHACES–>MRI/MRA head/neck, echocardiograms

85
Q

List 4 contraindications for propranolol.

A

HR< 80
BP< 50/30
Asthma
Decompensated heart failure
Heart block > 1st degree

86
Q

List 5 side effects of propranolol therapy.

A

a. Bronchospasm
b. Hypoglycemia
c. Disrupted sleep
d. Bradycardia
e. Hypotension
f. Diarrhea
g. Somnolence

87
Q

What is the initial dosing of propranolol (mg/kg/day)?
What is target dosing?

A

1 mg/kg/day in divided doses

2-3 mg/kg/day, max 3.4

88
Q

Can propranolol be used for RICH/NICH?

A

n0

89
Q

8) During which phase of the natural history of a hemangioma is the use of propranolol most beneficial?

A

proliferative
early proliferative 0-3 months, late proliferative 3-8 months

90
Q

9) When should propranolol typically be administered during the course of the day?

A

W/ feeds

91
Q

10) List 4 early and 4 late signs of hypoglycemia.

A

Early: shaking, fussy mood, irritable, tachy, diaphoretic
Late: Poor appetite, lethargy, seizures, hypothermia

92
Q

What are the 3 interconvertable forms of Vitamin A/retinoids?

A

Retinol–> Retinal–> Retinoic acid

93
Q

What are 3 dietary sources of retinoids? Where retinoids/derivatives stored in the body? How are they transported?

A

Orange/yellow vegetables, dairy, fish, meat, eggs, leafy greens

Stored in liver

Transported by retinol binding protein and transthyretin

94
Q

What are the 2 broad categories of retinoic acid reecptors? How many isotypes are contained within each group?

A

RAR
RXR

Each have alpha beta gamma isomer

95
Q

In 3-4 bullet points, explain the MOA of retinoids once inside the cell and any downstream effects.

A
  • Inhibits transcription factors AP1 and NF-IL-6, TLR2 = decreases inflammation and cell proliferation

-Increases Th1 and decreases Th2 responses (e.g. effective against CTCL)

-↓tumorigenesis and induces apoptosis
- Antikeratinization by downregulating K6 and K16
-Inhibits ornithine decarboxylase

96
Q

How do retinoids act in the cell? Describe MOA

A

a. Once in cytosol, transported to nucleus via Cytosolic Retinoic Acid Binding Protein (CRABP)
b. In nucleus bind to TF’s RAR and/or RXR, which bind to “RARE= retinaoic acid response elemtns” in genes regulated by these TFs

97
Q

List 3 first generation retinoids, 2 second generation retinoids and three third generation retinoids. Which ones are oral and which ones are topics?

A

TIA AcE BATT:

1st gen both, 2nd gen oral, 3rd gen topical *except box
a. First generation:
i. Tretinoin – topical (oral does exist)
ii. Alitretinoin – oral (topical does exist)
iii. Isotretinoin – oral (topical does exist)

b. Second generation:
i. Acitretin - oral
ii. Etretinate - oral

c. Third generation:
i. Adapalene - topical
ii. Tazarotene - topical
iii. Bexarotene – oral and topical

98
Q

6) What is Aklief? What is name of the retinoid in aklief?

A

Trifarotene
Topical retinoid for face/body acne

99
Q

7) What are 5 FDA approved indications for topical retinoids?

A

a. Acne vulgaris (tret, adapalene, tazarotene, trifarotene)
b. Psoriasis <20% BSA (Tazarotene)
c. AIDS-related Kaposis Sarcoma (alitretinoin)
d. Fine lines/wrinkling/mottled pigmentation/rough texture (tret, tazaoretene)
e. CTCL (IA/IB) (bexarotene)

100
Q

8) What are 3 FDA approved indications for systemic retinoids?

A

a. Psoriasis-Acitretin
b. CTCL-Bexarotene
c. Acne-Isotretinoin

Toctino/alitretinoin-hand dermatitis

101
Q

List 10 adverse effects of topical retinoids (126.6).

A

a. Erythema
b. Scaling
c. Peeling
d. Drying
e. Pruritus
f. Burning
g. Photosensitivity
h. Hypo or hyperpigmentation
i. Ectropion
j. ACD
k. Sticky skin

102
Q

What are 4 systems (broadly) are affected in retinoid embryopathy?

A

Cardiac/vascular
CNS
Craniofacial
Pharyngeal pouches

103
Q

11) List 6 acute effects of systemic retinoids as it pertains to each of the following systems:
Mucocutaneous
Ocular
Systemic
lab

A

i. Xerosis with pruritus
ii. Cheilitis
iii. Skin fragility
iv. Dry eyes, mouth, nose with epistaxis
v. Retinoid dermatitis
vi. Palmar plantar peeling
vii. Granulation tissue with pyogenic granuloma like lesions
viii. Nail fragility
ix. Photosensitivity
x. Alopecia/telogen effluvium
xi. Sticky skin syndrome

i. Decreased night vision
ii. Xeropthalmia (dry eye)
iii. Blepharoconjuctivitis
iv. Blurred vision
v. Photophobia
vi. Keratitis
vii. Corneal ulceration

i. Arthralgia/myalgia
ii. Pseudotumor cererbri
iii. Worsening depression/suicidality
iv. Anorexia, nausea, diarrhea, abdo pain
v. Fatigue, lethargy, irritable
vi. Toxic hepatitis
vii. Hypothyroid  Bexarotene
viii. Pancreatitis/TG elevation

d. Laboratory:
i. Hyperlipidemia: major concern TGs, can see elevated LDL, cholesterol, decreased HDL
ii. Transaminitis
iii. Agranulocytosis (Bexarotene)
iv. Leukopenia (Bexarotene)
v. Decreased T4 (Bexarotene)
vi. Thrombocytopenia/thrombocytosis
vii. Elevated CK
viii. Hypercalcemia (rare)

104
Q

12) List 3 chronic mucocutaneous effects of systemic retinoids.

A

Alopecia
Dry eye
Corneal opacities

105
Q

13) List 5 chronic systemic effects of oral retinoid use.

A

a. DISH-like bony changes
b. Osteophyte and bony bridge formation
c. Anterior >posterior ligament spinal calcification
d. Premature epiphyseal closure
e. Periosteal thickening
f. Myopathy
g. Osteoporotic changes in long bones

106
Q

What are the contraindications for systemic retinoid use?

A

Absolute:
-Pregnant
-breastfeeding,
- hypersensitivity
isotret-paraben anf soybean oil, epuris also soy, Clarus soy nd paragons

Relative:
i. Leukopenia
ii. Severe hypertriglyceridemia or hypercholesterolemia
iii. Significant liver or renal impairment
iv. Hypothyroid-bexarotene
v. Psuedotumor cerebri
vi. Depression

107
Q

List 4 important drug interactions when prescribing oral retinoids.

A

a. Vitamin A: hypervitaminosis)
b. Alcohol: liver risk, converts acitretin into etretinate
c. Tetracyclines: increased risk pseudotumor cerebri
d. Methotrexate: liver impairment, can be use in certain situations
e. Macrolide, Azalide antibacterials (Erythromycin&raquo_space; Clarithromycin > Azithromycin): CYP3A4 inhibitors which ↑ retinoids drug levels and resultant toxicity—lipids, liver toxicity, etc.; given that systemic retinoids do not have a narrow therapeutic index, thus more moderate risk vs. CsA.

108
Q

What is the typical therapeutic target dose for Accutane? What would be the target dose for a 75kg male who is about to initiate therapy with Accutane?

A

a. Total target: 120-150 mg/kg total  9000-11250
b. Target daily dose: 0.5-2 mg/kg/day Target dose up to 150 mg po daily (this is quite high, most would target 75 mg daily but technically up to 2 mg/kg allowed)

109
Q

What is the wavelength range of UVA?

A

320-400

110
Q

What is the wavelength range of UVB?

A

280-320

111
Q

What is the definition of minimal erythema dose (MED)?

A

a. the lowest dose that causes a minimally perceptible erythema reaction at 24 hours after irradiation.

112
Q

How are doses of light therapy generally determined?

A

70% MED or by skin type

113
Q

What is the mechanism of action of psoralens + UVA?

A

a. Psoralens activated by UVA photons, results in 2 reactions
-Type I reaction (direct) results in photoaddition of the compound to pyrmidines in DNA, forming monofunctional adducts and crosslinking DNA = DNA synthesis suppression.
-Type II (indirect) results in generation of ROS that causes cell membrane/constituent damage
iii. Also stimulated melanocytes, selective immunosuppression

114
Q

What are the side effects of PUVA? List 5

A

i. Pruritus
ii. Erythema
iii. Ankle edema
iv. Phototoxic reaction
v. Koebner phenomenon
vi. Friction blisters
vii. HSV recurrences
viii. Photosensitive eruptions’

ix. Due to methoxsalen alone
1. Nausea/GI disturbance
2. CNS disturbance
3. Hepatic toxicity
4. Cardiovascular stress
5. Bronchoconstriction
6. Drug fever
7. Exanthem

i. Photoaging
ii. NMSC
iii. Melanoma-controversial

115
Q

PUVA increases risk for which NMSC?

A

SCC

116
Q

What ocular issues are there with PUVA

A

cataracts

117
Q

What are the contraindications of PUVA? Name 5 absolute, 5 relative

A

Hypersensitivity to psoralens
Pregnant/Breast feeding
Lupus, XP, BP, PV, OCA, porphyria

Relative:
Hx skin cancer
Photoaggravated condition/photodermatosis
Cardiac, liver, renal dysfunction
Prior radiation or arsenic exposure

118
Q

What is wavelength nvUVB

A

311-313

119
Q

What are the side effects of NBUVB?

A

HSV recurrence
burning
pruritus
photoaging
Blpeharitis
bullae on psoriatic plaques
PMLE

120
Q

Name 5 conditions for nbUVB

A

Psoriasis
AD
Vitiligo
LP
PR
GA
PMLE

121
Q

Excimer laser wavelength

A

308

122
Q

What is benefit of excimer laser

A

High dose in localized area w

123
Q

Contraindications for NBUVB

A

a. Absolute: Pemphigus, pemhigoid, lupus, XP
b. Relative: Hx or fam hx of NMSC, melanoma, photodamage

124
Q

List 3 oral antiviral medications commonly used.

A

Acyclovir
Valacyclovir
Famciclovir

125
Q

What is the mechanism of action of acyclovir

A

Undergoes phosphorylation by viral thymidine kinase to acyclovir monophosphate, then 2 additional phosphorylations by host enzyme to become acyclovir triphosphate

inhibits viral DNA polymerase by serving as DNA obligate chain terminator (competes with deoxyguanosine triphosphate) = decreased viral replication

126
Q

What is one mechanism of resistance to acyclovir? What 2 medications can you use instead?

A

If resistance emerges, often due to thymidine kinase mutation,

can still use foscarnet and cidofovir that act direct on DNA polymerase

127
Q

What are the dermatological uses of acyclovir? List 3.

A

HSV-first episode, recurrence, suppressive,

Varicella zoster

Herpes zoster

Recurrent EM proven to be associated with HSV

128
Q

What are some side effects of acyclovir therapy?

A

N/V
Diarrhea
Headache

Phlebitis if IV
renal failure with rapid IV

129
Q

What is the mechanism of action of cidofovir? How is it different from other antiviral agents?

A

Does NOT rely on phosphorylation by viral thymidine kinase

MOA:
-Nucloeside phosphate analog of deoxycytodine monophosphate = competes with substrate for viral DNA polymerase, incorporates into DNA and inhibits DNaAsynthesis and replication

130
Q

What are 5 indications for cidofovir

A

CMV retinitis
HSV
Orf
HPV
Molluscum

131
Q

What is the mechanism of action of Foscarnet?

A

Pyrophosphate analog, binds and prevents DNA polymerase from DNA elongation

132
Q

What are 2 indications for foscarnet

A

CMV retinitis in AIDS
Acyclovir resistant HSV

133
Q

5 side effects foscarnet

A

Nephrotoxicity
Electrolyte abnormalities-
including hypocalcaemia, hypophosphatemia, hyperphosphatemia, hypomagnesaemia, and hypokalemia

Thrombophlebitis
Seizures
Penile erosion

134
Q

What are the s/e of Cidofovir?

A

Alopecia
Neutropenia
Nephrotoxicity
Cardiomyopathy
iritis

135
Q

What is 1 s/e of cidofovir

A

Nephrotoxicity

136
Q

What are the 3 side tx for warts other than imiqimod and 5-fu

A

Podophylotoxin
Sinecathecins
Cantharadin

137
Q

What is the MOA podofilox

A

Anti-mitotic agent that binds to tubular, cell arrest in metaphase

138
Q

What is the FDA indications podophylotoxin

A

genital warts

139
Q

What is the MOA cantharadin? where is it derived from? What is a side effect

A

Blistering agent- disrupts desmosomes and causes intraepideraml pacantholysis

Spanish fly/blister beetle/Lytta Vessicatoria

Can lead to ring wart formation

140
Q

What is veregen

A

Sinecathecin

derived from green tea leaves- derived polyphenol epigallocatechin gallate

141
Q

What is the MOA and indication for veregen

A

• Green tea (Camellia sinensis)–derived polyphenol epigallocatechin gallate → apoptosis, inhibition of telomerase, and an antioxidant effect on cells
• Approved for genital/perianal warts; SEs are local (e.g., upain, itch, and swelling)

142
Q

What are 3 examples of commonly used azoles

A

Fluconazole
Itraconazole
Ketoconazole *less often

143
Q

What are 3 examples of commonly used azoles

A

Fluconazole
Itraconazole
Ketoconazole *less often

144
Q

2) What is the MOA of azole antifungals?

A

Inhibits 14 alpha demethylase, prevents conversion of lanosterol into ergosterol import for cell membrane synthesis

145
Q

How is itraconazole metabolized and what is necessary for its absorption?

A

Liver-Cyp 3a4
acidic

146
Q

What are the FDA approved indications for itraconazole

A

Onychomycosis-dermatophte
Oropharyngeal candida
Aspergillosis, Blasto, histo

147
Q

Dosing for itraconazole for onychomycosis

A

200 mg daily x 3 month
or
200 BID x 1 week x 2-4 pulses

148
Q

What are itraconaolze contraindications

A

CHF, ventricular dysfunction,
Pregnancy
Hypersneisivity to itoa or prior azaleas
Concomitant medications: c yp3a4 substrates
See below

149
Q

Name the contraindicated medications for itraconazole use?

A

CYP3A4 substrates as it is a CYP3A4 inhibitor and will increase levels of the medications, can lad to prolonged QT and tornadoes

i. Cardiac: Statin (simva, lova), warfarin, riva, quinidine, dofeletide/disopyramide/dronedarone (anti-arrhythmics)
ii. Abx: Clarithro/erythro
iii. Immune modulators: Tacro, CsA, dapsone, colchcine,
iv. Psych: midaz, triazolam, Methadone, luradisone, Pimozide (Tics)
v. Misc: cisapride (GERD, off market), ergot alkaloids (PPH, migraines)

NAME 8:
Cisapride
Pimozide
Quinidine
Statins
Erythro/clarithro
Dapsone, colchicine, tacro, csa
Dofeletide,
Ergot alkalooids
Midaz
Lurasidone
nisoldipine

150
Q

What are the common side effects of itraconazole therapy?

A

a. Common/nuisance: GI (nausea, vomiting, diarrhea, abdominal pain), cutaneous (rash), neuro (headache), edema, LE rise, rhinitis, fever
b. Serious/rare: Neuro (hearing loss, peripheral neuropathy), CV events/CHF (torsades, QT prolong), GI (dysgeusia, hepatotoxicity, pancreatitis) labs (neutropenia/leukopenia, hypokalemia), pulmonary edema,

151
Q

How is Fluconazole metabolized and what is necessary for its absorption?

A

Very little hepatic metabolism

152
Q

What are the FDA approved indications for fluconazole? Off-label?

A

a. Oropharyngeal/esophageal/vaginal candidiasis, cryptococcal meningitis

b. Off label: tinea, cutaneous candida, systemic candida, onychomycosis (150-300 mg once a week for 3-6 months or 9-12 months for toes), coccoidal meningitis

153
Q

What CYP does fluconazole inhibit

A

CYP 2C9

154
Q

Name the contraindications to fluconazole

A

Known hypersensitivity to fluctuate or other azaleas

o Do NOT administer with pimozide, quinidine, cisapride, erythromycin, TERFENADINE, astemizole, voriconazole, or statins or 2c9 substrates

155
Q

What are the common side effects of fluconazole therapy?

A

Common: GI, headache, skin rash 9exfoliative)
Serious:
GI: hepatotoxicity, dysguesia
CV: Cardiac toxicity e.g., Torsades
Skin: Severe skin
Neuro: seizures
Blood-cytopenias
Labs: Hyperlipidemia

156
Q

Compare and contrast itraconazole in terms of cardiac toxicity, liver toxicity and medication interactions, and neurological s/e

effectiveness on sites

A

Cardiac: Both increases risk arrhythmia, itra CHF is contraindicated
Liver: higher risk itraconazole
Drugs: higher risk itra (at doses of flu 200)

ITRACONAZOLE risks of cytopenias, hearing loss, neuropathy vs. seizures w/ fluc

OVerall: Fluconazole best tolerated, secreted into sweat glands, great for skin, candida good,but not good for nails. Less liver toxic.

Itra better for nails, also good Canada, higher risk liver. take with coke. more drug interactions. More cytopenias, hearing loss, neuropathy.

157
Q

13) What are some unique side effects of voriconazole therapy?

A

Photoxicity
XP-like changes
Increased risk SCC
Psuedoporpyria

158
Q

14) What is the MOA of allylamines?

A

a. Inhibits squalene epoxidase prevents conversion of squalene to lanosterol, squalene builds up=toxic and decreases cell membrane synthesis

159
Q

15) How is terbinafine metabolized

A

Liver- CYP 2D6

160
Q

What are the indications FDA for terbinafine

A

Dermatophyte onychomycosis
Tinea capitis

Off-label: tinea infections, subcutaneous/systemic mycoses (e.g., histoplasmosis and chromoblastomycosis), and other types of onychomycosis (good for Aspergillus, but not Candida)

161
Q

List 3 systemic antiparasitic agents and 4 topical antiparasitic infections.

A

Albendazole
Ivermectin
THiobendazole

Topical:
Permethrin
Malathion
Albendane
Spinosad
lindane

162
Q

What is the MOA of ivermectin?

A

Binds glutamate gated chloride ion channels in parasite nerve and muscle cells, hyper polarizes and can cause cell death

163
Q

What is the FDA indication for ivermectin- 2

A

Strongyloides
Onchocerciasis

164
Q

What are off label uses of ivermectin

A

Larva migrans
pediculosis
scabies

165
Q

What are important s/e of ivermectin, what is the mazotti reaction and how is it treated

A

Rash
itch
Fever
LAD

Death and encephalopathy in those w/ loiasis

Mazotti:
urticaria
fever
edema
hypotension
arthralgia
abdominal pain
ocular sx

  • more common when treating onchocerciasis,
    can tx w/ doxy
166
Q

MOA albendazole

A

Stops tubular polymerization–> causes immobilization and death

167
Q

NAme 2 FDA indications albendazole and 4 off label indications

A

FDA:
Neurocystisercosis, Hyatid disease

Off label:
Strongyloides stercoralis, Giardia, scabies, Necator americanus (hookworms)

Others:
Ascaris lumbricoides, Trichuris trichiura, Enterobius vermicularis, Ancylostoma duodenale and Taenia,

168
Q

8) What are important side effects of albendazole?

A

Bone marrow suppression: aplastic anemia and agrnaulocytosis
Hepatotoxicitty

169
Q

MOA permethrin

A

Disabels sodium transport channels on cell membrane–> paralysis

170
Q

What are 2 uses of permethrin and how are they applied

A

Scabies
Pediculosis capitis

Apply to entire body neck down, x 2, 1 week apart, 8-12 hrs

5% for scabies, 1% pediculosis

171
Q

What is the MOA of malathion? List 4 side effects. list the main use

A

Malathion- Organophosphate that inhibits acetylcholinersterase in arthropods- leads to paralysis

Use: pediculossis capitis

S/e: Flammable, local irritation, malodorous, when ingested organophosphate poisoning

172
Q

MOA of lindane

A

Organochloride-decreases neurotransmission via inhibitions gaba gated chloride channel- paralysis

173
Q

What is lindane used for?

A

pediculosis as 2nd line agent

174
Q

what is permethrin mc used for

A

scabies, pediculosis

175
Q

13) What is an important side effect of Lindane?

A

seizures/neurotoxic, aplastic anemia, leukemia

176
Q

NAme 4 tx for pediculosis

A

malathion
permethrin
lindane
spinosad

177
Q

Name 2 treatments for scabies

A

permethrin topical
oral ivermectin

MyDermatology-Bolognia (31 decks)

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