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1
Q

How would you treat MTX overdose?

A

leukovorin 15-25 mg PO Q6 hrs x for up to 10 doses

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2
Q

thalidomide - approval?

A

multiple myeloma: CAD

FDA: EN leprosum

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3
Q

thalidomide - 3 derm uses?

A 
PG
Behcets
Chronic spontaneous urticaria
BP
Pompholyx
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4
Q

hydroxyurea - 5 s/e?

A

chemo drug so -> myelosupression, anagen effluvium, bacterial infecitons
known for ulcers and hyperpigmentation ; UTD eczema, xeroderma
HA, GI fox, anemia, arthralgia, 2’ malignancies from suppression

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5
Q

MMF - active metabolite?

A

mycophenolic acid

6 MP - mercaptopurine is AZA, do not confuse

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6
Q

MMP MOA?

A

MA: Marine -> + BAPTIzeD

T/B cells -> Iono monophosphate or xanthine monophosphate -> iono monophosphate dehydrogenase -> guanosine monophosphate -> purine metabolites blocked

T cells don’t have salvage pathway to go through

decreases B cell production, Ab synthesis
decreases purine synthesis
T cell production
pro-Inflammatory cell recruitment decreased due to down regulation of E/P selectins
ZZZ - fibrosis -> decreases action of fibroblasts involved in tissue fibrosis
dendritic cells - exerts effect on

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7
Q

MMF MC S/E?

A

GGreaT CHIN
GI upset dose dempendent
divide doses, enteric coated tablets, take with food, give tiem

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8
Q

MMF - 5 side effects?

A

GGreaT CHIN floating above water
GI - N/V/D, GI upset, loose stools, ANAL tenderness ~~~~~
GU - sterile pyuria ~~~, dysuria, frequency, urgency , NO nephrotoxicity
T - teratogenic EEC - ears, eyes, cleft
Carcinogenic - lymphomas, conflicting NMSCa
Heme - agranulocytosis, neutropenia, anemia
Infections - ZOster > bac > viral
Neuro - weakness, fatigue (“swim”), tinnitus (“water in ears”), insomnia

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9
Q

drug that increases MMF availability?

A

probenecid
antivirals (acyclovir) decrease tubular excretion
salicylates - displace from protein

others in notes: cholestyramine, Abx

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10
Q

what is the difference btwn MMF and MPA? brands?

A

mycophenolic acid = MMF

active metabolite MPA = myfortic`

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11
Q

MMF - what does it act on ?

A

“lymphocytes”, T cells&raquo_space; B cells - inhibits purine metabolites, T/B cells have no salvage pathway

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12
Q

what does of MMF increases infection rates

A

> 2 g/day

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13
Q

MMF typical dose?

A

start at 500 and slowly bring to 2-3 g /daily divided into BID (aka 1000 mg BID)

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14
Q

difference between myfortic and cell cept

A 
myfortic = EC-MPA (720mg, equivalent to 1 g MMF)
cellcept = MMP
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15
Q

MMF - c/i

A

absolute: pregnancy, hypersensitivity
relative: chin to belly button
lactation
peptic ulcer dz
cardiopulmonary dz
renal dz
hepatic dz
DRUG INTERACTION (CHLESTYRAMINE)

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16
Q

MMF - how many weeks/months before pregnancy?

A

6 weeks

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17
Q

CsA - 6 s/e?

A

HeLLMans Real Good or derm and non-derm

Hypertrichosis
HyPOMg, HyperK, HyperUricemia 
Heme abn - anemia, lymphopenia, neutropenia
Hyperplasia - Gingival
Lipids - hypertriglycerema
Liver - transaminase elevation
Malignancy - CTCL, NMSCa

Renal
GI

Cutaneous: 
acne
epidermoid cysts
sebaceous hyperplasia
NMSCa
hypertrichosis
gingival hyperplasia

or F THINGS - flushing trichomegaly trichodysplasia spinulosa hypertrichosis
infections NMSCa gingival hyperplasia, sebaceous hyperplasia, acne

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18
Q

skin s-e (5) of CsA?

A 
Cutaneous: 
acne
epidermoid cysts
sebaceous hyperplasia
NMSCa
hypertrichosis
gingival hyperplasia

or F THINGS - flushing trichomegaly trichodysplasia spinulosa hypertrichosis
infections NMSCa gingival hyperplasia, sebaceous hyperplasia, acne

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19
Q

drugs that will increase renal tox in CsA?

A 
CANTS
Cimetidine
ampho B/azoles
NSAIDS (renal yo)
Tacrolimus (same classs = bad news)
Septra - every list
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20
Q

relative C/I for CsA

A

2 Ds and a I
drugs - drugs that can interfere with absorption or metabolism of cyclosporine, esp renal dysfunction
drugs - phototherapy, MTX and other immunosupresants = > cancer increase

demographics - pregnant
demographics - lactating
demographics - <18 > 65
demographics - unreliable

infection - active infection
infection - vaccination , live
infection - immunodeficiency

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21
Q

adalimumab - structure?

A

fully human mono Ab

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22
Q

6 s/e of adalimumab?

A 
injection site reaction
drug induced LUPUS!
increased risk of infections
NMSCA increased risk
malignancy increased risk

c/i with CHF and demyelinating conditions

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23
Q

adalimumab - approval? dose?

A 
PsO and PsA in adults
Ank Spond
RA
UC /Crohns
uveitis
HS
JIA
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24
Q

adalimumab - PsO dosing

A

80 mg x 1 , 40 mg at W1 and Q2 W

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25
Q

advantage of quantiferon?

A

previous BCG, unreliable (faster results), pts on immunosurpession

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26
Q

atypical antipsychotics - MC s/e? 5 others?

A

sedation

metabolic - weight gain, hyperlipidemia, gynecomastea
DM, seizures, h/a
decreased sex drive
QT prolongation important

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27
Q

3 metabolic pathways of CsA?

A

CYP3A4, CYP3A5, p glycoprotein?

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28
Q

5 drugs that can increase CsA levels?

A 
Stop Cyber Kids From Eating Grapefruit and Plums
Abx AntiHTN Other
Septra
statins
SSRIs
cimetidine
CCBs
cephalosporine
ketakonazole, other azoles
furosemide
erythromycin, other macros
Grapefruit
PROTEASE INHIBITORS aka antivirals

INHIBIT CYP 3A4

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29
Q

drugs that induct CYP3A4 aka can decrease CsA levels?

A

anti seizure meds basically (destimulate brain but stimulate CYPS)

CROPS
carbamazepine
RIFAMPIN
OCTREOTIDE
phenytoin
phenobarb
St jons wort
glucocorticoids in some lists
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30
Q

CsA dose?

A

3-5 mg/kg

start at 3 mg divided BID

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31
Q

5 TNFs? administration ? molecule?

A 
adalimumab, SQ, fully human
golimumab, SQ/IV, fully human
infliximab, IV, humanized (X) - chimeric
certolizumab pegol, SQ/IV,  human
etanercept, SQ, fusion p75 TNF and FC - fully humanized
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32
Q

MOA of 5 FU

A

DNA and RNA

thymidylate synthase (TS) inhibitor
DO NOT CONFUSE with THYMIDINE KINASE - viral

blocks synthesis of nucleotides required for DNA (scarcity of dTMP)
incorporates into RNA - > damage and termination of translation

Nature:
5-Fluorouracil (5-FU) can activate p53 by more than one mechanism: incorporation of fluorouridine triphosphate (FUTP) into RNA, incorporation of fluorodeoxyuridine triphosphate (FdUTP) into DNA and inhibition of thymidylate synthase (TS) by fluorodeoxyuridine monophosphate (FdUMP) with resultant DNA damage.

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33
Q

5 FU - approved indications?

A

AK: BID x 2 weeks face, 4-6 weeks body

sBCC BID 3-6 weeks

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34
Q

what cytokine does CsA down regulate?

A

IL 2

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35
Q

MTX - 3 ways to decrease GI tox?

A

SQ, decrease dose, split dose (esp PO into 3 doses Q 12)), folic acid

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36
Q

rituximab - cell target?

A

CD20 Mature T cells

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37
Q

ritux - 4 c/i?

A

CAN: hypersensitivity, severe infection, progressive multifocal leukoencephalopathy (IL)

BHA yo

hx of bronchospasm
HYPOtension
angioedema

aka infusion reaction - if any of these would make way worse

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38
Q

ritux dose?

A

1000 mg IV x 2 separated by 2 weeks

or 375 mg/m2 Week x 4 heme

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39
Q

2 derm indications of ritux? others?

A

GPA, MPA

NHL, CLL, RA
Canadian : cd 20 + diffuse large B cell , follicular cd 20+ , nhl

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40
Q

ritux - 5 s/e

A

MC - infusion rxn ; A Right TITI
Anemia, Tumour lysis, Infection, Tumours (SCC< Merkle), Infusion

Usuals: HTN, N/URTI, arthralgia, pyrexia, pruritis
infection - bacterial, viral, fungal
progressive multifocal leukoencephalopathy

tumour lysis syndrome - rapid decline in renal fxn
malignancy (SCC and Merkel reported)

cytopenia - late onset usually (weeks to months, neutropenia)

infection reactivation like Hep B, JC virus

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41
Q

ritux - 6 investigations?

A

CBC (cytopenias)
HIV
Hep B/C
TB + CXR

CBC Q2 weeks during Tx and Q1-3 weeks thereafter
for pemphigus, titres Q6-12 months, titres will rise before sx - retreat

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42
Q

ritux - 5 off label skin indications?

A 
BP,  PV, PF, paraneoplastic, EBA, MMP
DM and SCLE
GVHD
VASCULITIS - including eGPA/GPA (official indication), cryoglobulinemia, HPS
B cell lymphoma
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43
Q

which drug should not be combined with ritux?

A

cisplatin - increased tox

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44
Q

Vaccines - live and not recommended on immunosuppressants?

A

ROME Is MY Best Vacation
Rubella
oral polio
Mealses,

Influenza, oral

Mumps
Yellow fever

bCG
VZV

SHINGRIX is not LIVE, zostavax is live but less effective

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45
Q

when to administer vaccines before biologics?

A

ideally 4 weeks prior
PHARma

Polio IM
pneumococcus 
HPV
Hep A/B
Rabies

ma

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46
Q

which cells are CD20+

A

transitional B cell
mature B clel
memory B cell
Plasma cell (CAN BE CD20 + or negative)

essentially CD20 - plasma cells in the bone marrow continue producing Ig and CD20- cells that are long lived continue to protect against antimicrobial Ab, but short lived plasmas which tend to be reactive are wiped

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47
Q

ritux - MOA

A

CHIMERIC murine human Ab against CD 20 (chimeric so like infliximab way more infusion rxns)
-> depletes CD20+ B cells which tend to be auto reactive (immature, transitional, mature and memory)

kill cells via 3 ways -> complement mediated, Ab-dependent via NK cells, inhibition of growth signals and induction of apoptosis

also shown to decrease regulatory T cells

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48
Q

MTX + septra -> risk?

A

myelosupression/bmt failure

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49
Q

biologics - which vaccines c/i?

A

Rome Is my best vacation

VZV, MMR, BCG, influenza oral, oral polio, zostavax

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50
Q

dupi - which 2 IL targeted

A

targets IL 4 R
Type 1 - IL 4
Type 2 - IL 4 and13

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51
Q

3 IL 23s?

A

guselkumab, tildakizumab, risankizumab

Tilda swinton wearing Bjorks Goose dress - couldn’t rise to sky

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52
Q

guselkumab dose?

A

SQ 100 Q0, 4 and Q8 (g 8 se)

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53
Q

skyrizi dose?

A

150 W 0, 4, 12 and Q12

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54
Q

skyrizi - approval for?

A

IL 23, PsO

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55
Q

tildrakizumab - IL, approval, dose?

A

100 mg (sky rizi is the only one 150 in IL 23 b.c “higher in the sky”)
PsO - adults
SQ 0, 4, Q12

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56
Q

IL 23 s - s/e

A

URTIs MC
injection site rxns
arthralgia
GI reported including diarrhea

increased transaminases in PsA Guselkumab

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57
Q

IL 23s MOA?

A

binds to p19 subunit of IL 23- > prevents its interaction with IL 23 R -> Th 17 downregulated - > decreased production of IL 17 A, F, 21, 22 etc

58
Q

PsO biologics approved for use in kids?

A

SEE Ur Ix (ex)

TNF alpha - etanercept
IL 17 - ixekizumab, secukinumab (not bro)
IL 12/23 - yes, ustekizumab
IL 23 - none

59
Q

4 RF for pancytopenia w/ MTX?

A

FOLaTe Rocks Daily - no folate, old, aLbumin, TMX - Septra, renal dz, incorrect dose (daily)

lack of folate
Old
renal dz ->  MTX skyrockets
hypoalbulinemia (goes with malnutrition nd hepatic imp)
drug interactions like septra

Risk factors for pancytopenia include advanced age, renal impairment, infection and hypoalbuminemia. Myelosupression is more likely if MTX is taken daily.

60
Q

3 things folate improves in MTX?

A

anemias, GI s/e
DECREASED LIVER TOX

aka 3 basic s/e

61
Q

5 skin dz worsened by TNF alphas?

A 
Pso 
SLE
vasculitis
infections like candida, HSV
lichenoid dermatitis
eczematous dermatitis
DM
62
Q

TNF alphas - MOA?

A

blocks TNF aphas

  • reduces neutrophil chemotaxis
  • down regulates intracellular adhesion molecules
  • reduces Th1 response (not in Wolverton though)
  • reduces keratinocyte proliferation
  • down regulates IL 22 receptors -> decreased pro inflammatory cytokines
63
Q

etanercept - approval and structure?

A

P 75 x 2 fused with Fc TNF alpha and beta

PsA, PsO, RA, Ank Spons, JIA (b/c kids)

64
Q

etanercept age for PsO?

A

kids 4 + (others are ixekixumab, secukinumab and stellara)

65
Q

etanercept dosing adults and kids?

A

50 mg BIW x 12 weeks, than OW

kids 0.8 mg/kg/week

66
Q

etanercept - s/e

A

TB reactivation, recurrent infections, do not initiate on active infections, lymphomas,
DO NOT USE WITH ANAKINRA OR DMARDS
relative CHF
personal or family history of demyelinating

other
vaccinations - must be current
infections
anaphylaxis
pancytopenia
lymphomas
preggo B
67
Q

infliximab - structure dose? indications

A

chimeric
5 mg/kg, adults only
RA, Ank spond, PsO, PsA, IBD

5 mg /kg W0,2, 5 Q8

68
Q

TNF alpha - 5 off label uses

A 
ada is HS + but others can be used too
neutrophilic dermis like PG and behcets
granulomatous dermis like sarcoid
vasculitis: takayasu, kawasaki
PRP and other Pso like disorders
69
Q

absolute c/i in TNFs?

A

AAA - anakinra
hypersensitivity
infections - active or chronic

relative CHF, demyelinating

70
Q

infliximab - drug specific s/e?

A

infusion reactions - headaches, flushing, dyspnea, bornchospasms, BP drop, cheapest pain, anaphylaxis

give tylenol and antihistamine before

also reports of liver failure, jaundice etc

71
Q

adalimumab - structure , approvals?

A 
HS 12+
PsO
PsA
RA
JIA
ank spond
IBD - both
uveitis

human gig recombinant Ab TNF alpha only (TNF alpha and beta in etanercept)

dose 80 mg W0, 40 mg W1, 3, 5 , 7 Q2 thereafter for PsO

!!!!HS: 160 mg W0, 80 mg W 2, 40 mg W 4 Qw

72
Q

adalimumab - dosing

A

human gig recombinant Ab TNF alpha only (TNF alpha and beta in etanercept)

dose 80 mg W0, 40 mg W1, 3, 5 , 7 Q2 thereafter for PsO

!!!!HS: 160 mg W0, 80 mg W 2, 40 mg W 4 QW

73
Q

certolizumab pegol - preggo category and dose?

A

preggo: no official category : “may be safe to continue in pregnancy”
humanized Ab
does not cross placenta because PEG and not IgG

RA, PsA, PsO, Ank sond

400 mg W 0, 2, 4 -> 200 mg W2 w

74
Q

TNF alpha required labs?

A

TB, Hep B, C - historically repeated annually, now if not high risk can skip

rare cases of anemia, pancytopenia, LFT elevations - CBC and LFTs before start especially infliximab

75
Q

TNF alphas - s/e ? (again)

A 
infection
malignancy
CHF
demyelinating disorders
injection site/infusion site
skin - SLE, AD, PsO and others

reports of heme and LFT abn

76
Q

MOA IVIG?

A

Fast (or FAT :) ) CAT moves slowly on steroids

blocks FAS from interacting with its ligand
Complement inhibition
reduction in C3/C5 convertase aka they don’t get cleaved and membrane attack complex not formed
decreases Ab production by active B cells
T cell - reduces the number of auto reactive T cells, supresses T cells
slowly - inhibits cellular adhesion and migration into target tissues
increases sensitivity to glucocorticoid receptors

77
Q

IVIG - approval? 5 common derm uses?

A

formally immunodeficiencies only
MC Kawasaki w/ ASA (2 g/kg/day)
DM and AI blistering - PV/BP/PF/MMP, EBA, LABD

also scleroderma, SLE, AD, urticaria, etc

78
Q

IVIG c/i - absolute and relative?

A 
absolute - anaphylaxis
relative - RA (RF up - nephrotox)
 IgA deficiency (anaphylaxis)
 renal disease
 cryoglobulinemia 
 CHF (fluid overload
79
Q

IVIG - preggo category

A

C

80
Q

IVIG = S/E

A

Thiin as Fluid

thromboembolic events
heme - hemolysis, anemia
infections - theoretic
infusion rxnx
neuro - ASEPTIC MENINGITIS
As - AsSEPTIC, anaphylaxis

fluid overload - CHF, renal
fluid filled lesions on hands

81
Q

IVIG - labs?

A

cryo, IgA level, RF, CBC, Cr/renal, Hep B/C, HIV, TB

82
Q

IVIG dose

A

2 g/kg/cycle over 4-5 hrs, divided into 3 doses on 3 days

Q4 weeks

83
Q

MOA - MTX

A

inhibition of DIhydrofolate reductase = irreversible
inhibition of thymidilate SYNTHASE - reversible (time Sensitive)
reduction in folate synthesis -> blocks DNA synthesis

AICAR - decreased adenosine, antiinflammatory

84
Q

c/i drug with MTX?

A

septra

85
Q

rituximab target and mode of administration

A

anti CD20 - wipes mature B cells, memory B cells and plasma cells that are CD20+
IV 1 g DO and 14 than repeat PRN
CBC at administration and Q2 weeks during tx and follow Q3 months thereafter

86
Q

5 CsA c/i s?

A

hypersensitivity to cyclosporine
HTN - uncontrolled
malignancy - active, CTCL
renal failure or sign decrease in function

demographics - preggo, lactating, <18 > 65, unreliable
drugs - CANTS, phototherapy, MTX
immuno - immunodeficiency, active infection, vaccines

87
Q

CsA - 6 labs?

A

i2 BP measures at least one day apart

CBC, LFTs, Cr/Urea, U/A, FASTING lipids, Mg, K, uric acid, preggo, Hep, TB, HIV

88
Q

what can you use in CsA hyperlipidemia?

A

rosuvastatin, fluvastatin, exercise

89
Q

what can you use in CsA HTN?

A

nifedipine

90
Q

what do you do if renal markers up by >25%? >50%

A

repeat in 2 weeks, if still elevated/sustained, decrease CsA by 1 mg/kg/day for 2-4 weeks and recheck, if normal continue and if not d/c

50% - dc until normalizes

91
Q

CsA - dose?

A

3- 5 mg/kg/day - recommended to start at 2.5 - 3
do not continue for more than 1 year in FDA

IDEAL weight

92
Q

MTX - 5 drugs that interact?

A

septra - BMT supression
dapsone - BMT suppression
Nsaids, salicylates - increase levels (NO pain meds)
CsA/other immunosuppressants - too much
others: probenecid, phenytoin, - increase tox
ALCOHOL< RETINOIDS -> hepatotoxic increase

93
Q

TNF alpha 7 s/e?

A 
infections
injection
CANCERS - NMSCa, Lymphomas
SKIN - Pso, Lupus, AD, etc
CHF 
demyelinating
`
94
Q

MTX - Pso indications (4)?

A 
plaque that is not responsive (>20 % BSA)
erythrodermic 
affecting EMPLOYMENT
pustular
PsA
poor response to Photo and retinoids

(not on monograph, just says severe disabling PsO)

95
Q

CsA s/e - 3 MC?

A

hypertrichosis #1
gingival hyperplasia
NMSCa

sebaceous hyperplasia, acne, epidermoid cysts etc

96
Q

what is chimeric? dimeric?

A

chimeric _ mouse and human fused - infilixibam

dimeric ? humanized but fused - ex etanercept?

97
Q

CsA - 2 types of renal toxicity

A

interstitial fibrosis /tubular dysfunction

prerenal - afferent arteriole vasoconstriction

98
Q

transdermal drug delivery - 5 factors that influence it?

A 
stratum corneum thickness
site
sebaceous gland density
hydration of stratum corneum
drug concentration
vesicle used
occlusion 
skin barrier dysfucntion/erosion/ulceration
99
Q

5 factors that can enhance transdermal drug delivery?

A 
physical:
iontophoresis
ultrasound - thermal or cavitational
fractionated photothermolysis
microneedling 
peels aak stripping
mechanical abrasion
chemical: 
water
solvents 
surfactants
nanoparticles

bio
peptides

100
Q

transdermal drug delivery - advantages?

A 
avoids GI metabolism
avoids hepatic metabolism
reduces patient cost
improves patient compliance
avoids pain of injection
improved efficacy (skin drug on skin)
101
Q

ideal transdermal drug?

A

small molecular weight
lipophilic
small concentration/dose needed to treat condition (so compounding not crazy)

102
Q

Ritux - MC and most worrisome S/E?

A

PHoNe for A C*nt and TITI

MC: pyrexia, hypertension, URTI, nausea, arthralgias
CYTOPENIAS - delayed (months sometimes), neutropenia; good reason for CBC Q3 mo
Tumour lysis , 24 hrs sudden decrease in renal fxn
Infection - reactivation or new
Tumours - SCC and Merkel reported
Infusion reaction - MC of all

BOLOGNA
Progressive multifocal leukoencephalopathy has been reported
Serious infections (bacterial, fungal, or viral) up to 1 year after completing therapy and reactivation of viral infections may occur, especially hepatitis B virus reactivation with fulminant hepatitis
Cardiac arrhythmias and angina can occur and may be life-threatening.
Bowel obstruction and perforation have been described
Stevens–Johnson syndrome/toxic epidermal necrolysis and onset of paraneoplastic pemphigus have been described

103
Q

rituximab - c/i?

A 
allergic to the drug
infusion drug SO:
CARDIAC ARRHYTHMIAS
angina pectoris
high tumour burden -> tumour lysis
active infection  and hepatitis B carriers (reactivation)
104
Q

what cells does ritux NOT affect?

A

PRO B cells (CD 20-), PLASMA cells are CD 20-

preB cells +, naive cells are, memory and plasma BLASTS are, some

105
Q

what cells does ritux target (be specific)

A

CD 20 +

pre B, naive B, memory B cells, plasma BLASTS

MA: MEMORY of BLASTS on PRENAtal wing of the hospital

106
Q

Omalizumab - MOA?

A

Omalizumab is a humanized IgG1 monoclonal antibody that selectively binds to and decreases serum levels of free human IgE. It also down-regulates the number of high-affinity IgE receptors on mast cells, basophils, and dendritic cells (Bologna)

107
Q

Omalizumab common s/e - 3

A 
Injection site reactions Bologna 10-15%
URITS
headaches
sinusitis
pharyngitis
viral infections

most dangerous anaphylaxis - prescribe epipen

preggo B

108
Q

omalizumab dose?

A

subcutaneous injection of 150 or 300 mg every 4 weeks for CIU,

109
Q

omalizumab - 3 cutaneous s/e

A

injection site
anaphylaxis
serum sickness like reaction
eGPA (eos)

110
Q

topical jaks in bologna?

A

Preliminary studies have shown benefit from topical application of tofacitinib 2% ointment for atopic dermatitis or psoriasis, and ruxolitinib 2% cream for facial vitiligo106

i think sofa is still 2% but ruxo is now 1.5%

111
Q

2 c/i to IL 17 (bologna)?

A

chronic/recurrent infections or inflammatory bowel disease,

112
Q

s/e IL 17 bologna?

A

MC nasopharyngitis, upper respiratory tract infections, and injection-site reactions

anaphylaxis, angioedema, and urticaria

Mucocutaneous candidiasis, most often oral or vulvovaginal, develops in ~5% of patients

. Neutropenia (<1500 cells/mm3) occurs in ~1–2% of patients

IBD

depression in broda

113
Q

dupilumab - target?

A

Dupilumab (Dupixent®) is a monoclonal antibody that targets the IL-4 receptor α subunit (IL-4Rα)

114
Q

MC side effect t- dupi (bologna)

A

conjunctivitis (see Table 128.6), with each occurring in ~10% of patients.

115
Q

IL 1 c/i and indications? Bologna

A

Currently, there are three approved IL-1 antagonists: anakinra, canakinumab, and rilonacept. Dermatologic uses of these medications include treatment of cryopyrin-associated periodic syndrome (CAPS) and the pustular eruptions and bone lesions (e.g. osteomyelitis) of the autosomal recessive deficiency of the IL-1 receptor antagonist (DIRA)

c/i hypersensitivity to drug, infection

116
Q

which class should not be co-administered with IL -1

A

TNF alphas

117
Q

s/e of anti-IL 1s? bologna , 2

A

serious infections, flu-like symptoms, and injection site reactions

118
Q

what is anakinra?

A

glycosylated human IL-1 receptor antagonist

119
Q

imiquimod - 3 concentrations, 3 approvals?

A

2.5%, 3.75%, and 5% creams, i

(1) anogenital warts
(2) actinic keratoses (AKs) on the face or scalp
and (3) superficial basal cell carcinoma (BCC) measuring up to 2 cm in diameter on the trunk, neck, or extremities (excluding the hands and feet)1

120
Q

imiquimod - list 4 off label uses including one non-viral infection?

A

common warts20, Bowen disease (squamous cell carcinoma in situ)21, nodular BCC, lentigo maligna, melanoma metastases, T-cell lymphoma, Paget disease, and leishmaniasis as well as prevention of keloid recurrence following surgical excision22

121
Q

imiquimod - dose for warts? BCCs ? AKs?

A

AGS (alphabetic)

AKs - 2/week x 16 w - clearance 50%
genital warts - 3/week x 16 w 50%
sBCC - 5x/week x 6 weeks 75% clearance

(Bologna)

122
Q

imiquimod MOA?

A

induces TLR7 - and through interferon gamma thought to switch Th1 response and cell mediated immunity

123
Q

imiquimod - preggo category?

A

B

124
Q

imiquimod - s/e

A

erythema, edema, scale, erosion, ulceration at application sites
more intense with ++ actinic damage
erosive pustular dermatosis of the scalp
flu like - fatigue, headache, diarrhea, myalgia - 1-2%

125
Q

tralo indication and MOA?

A

mod/severe AD in adult

anti IL 13 - inhibits its interaction with IL 13 receptor (IL 13 R alpha 1 and 2)

126
Q

tralo dose?

A

600 x 1 _> 300 Q2 weeks subq

127
Q

tralo c/i ?

A

hypersensitivity

128
Q

tralo MC side effect? 3 others?

A 
URTI (unlike dupi)
injection site
conjunctivitis
keratitis
hypereos
129
Q

dupi - indications (3)

A

think of atopic march
AD 6+
asthma 12+
rhino sinusitis Adult

130
Q

dupi - MOA?

A

IL 4 receptor antagonist

antagonizes type alpha subunit of IL 4 R, shared by IL 4 and 13

131
Q

dupi dose by weight > 60 <> 30 <>15 kg?

A

> 60 kg/adult 600 mg x 1 (2 sides) -> 300 Q2 weeks
30-60 400 mg x 1 -> 200 Q2 weeks
<30 but > 15 kg 600 mg x 1 -> 300 Q4 weeks

132
Q

off label uses of dupi?

A

AA, PF, PF, etc

133
Q

5 ocular s/e of dupi?

A

dry eyes, itchy eyes, keratitis, blepharitis, conjunctivitis (break to allergic, bacterial, viral, eye irritation, eye inflammation etc)

134
Q

dupi EASI 75?

A

50%

135
Q

dupi - top 3 s/e?

A

injection site #1
conjunctivitis #1 (shared)
HSV #2
herpes simplex #3

136
Q

difference in MOA between Tralokizumab and Dupilumab?

A

dupilumab is antagonist of IL 4 RECEPTOR -> blocks T1 IL 4 R and T2 IL 4 and IL 13
DupeR

tralokinumab is IL 13 neutrolizing Ab (aka IL 13 vs IL 4 > 13 and Ab not Receptor target)
IL 13 helpful in AD and itch induction

137
Q

Tralokizumab dose? indication?

A

moderate severe AD in adults

600 mg SQ -> 300 mg SQ Q2 weeks

138
Q

SteLLara MOA and dosing?

A

IL 12 and 13 IgG1 antagonist
PsO, PsA, IBD (crohns and ulcerative colitis)
6+ for PsO (MA: dupi 6, stellara 6, most kids are 6)

0.75 mg/kg in kids < 60 kg
45 mg SQ in adults < 100 kg
90 mg SQ in adults > 100 kg

W0, 4 and then Q12 (anti IL 12 !!! and 23 :) )

139
Q

Stelara c/i and warnings?

A

hypersensitivity
active infection, chronic infection, recurrent infection -> CAN LEAD TO SEVERE
caution with malignancy
LATEX capp
hypersensitivity including angioedema/anaphylaxis
allergic alveolitis/eosinophilic PNA reported
can be used with AZA, MMP, MTX

140
Q

Stelara - s/e - 7

A 
rhinitis
pharyngitis
URTIS  - other
h/a
arthralgia
---- MC
dizziness
N/V
pruritis
DEPRESSION recorded
injection site reactions
acne with IBD
nasal congestion
HSV, cellulitis, dental infections, candida vulvaginitis, etc

PASI 50 - 90%
75 - 71% and 90 50% aka 50-70 - 90

141
Q

What interventions can be combined with oral retinoids?

A

CsA (not hepatotoxic),
PUVA, UVB (even though can be photosensitiz.)
biologics

142
Q

how long post last use do you need to wait before pregnancy with isotretinoin? acitret? bexarotene? and half lives of each? dose of each?

A

isotretinoin 10-20 hrs, wait 1 month post, 0.5 -1 mg/kg/d
acitretin 50 hrs , wait 3 yrs? (monograph is 2 months, but theoretic risk of conversion to etretinate which has 120 d half life)
bexarotene 1 MONTH before and 1 month post (per monograph), 9 hrs, 300 mg/m2/d
alitret 9 hrs 30 mg/d 1 month post pregnancy

A Wolverton (13 decks)

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