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PHM 702: Pulm and ToXXX > S LEaving my brain at home > Flashcards

S LEaving my brain at home Flashcards

1
Q

SLE triggers

A
  • UV light triggers
  • stress
  • smoking
  • virus/virus ike elements
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2
Q

SLE dx

A

4 out of the following 11 SOAP, BRAIN, MD
1. serotosis
2. oral ulcers
3. arthritis
4. photosensitivity
5. blood disorders
- hemolytic anema w/ reticulocytosis
- leukopenia on 2+ occassions
- lymphopenia on 2+ occasions
- thrombocytopenia in absence of offending drugs
6. renal involvement: persistent proteinuria, cellular casts
7. antinuclear Ab
8. immunology/serologic testing
9. neurologic disorder (with unclear cause)
10. malar rash
11. discoid

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3
Q

SLE serologoic testing

A
  • ANA: if negative, pretty positive it’s NOT SLE, but if positive, eh
    • Good for excluding, not confirming SLE
  • Anti-dsDNA Ab: perform after ANA titer to confirm
  • Anti-Sm Ab: smith proteins
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4
Q

Antiphospholipid syndrome (APS)

A
  • secondary APS: aPL(+) AND thrombotic event
  • associated with DVTs, stroke, and neurologic manifestations
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5
Q

lupus nephritis (LN)

A
  • kidney inflammation d/t either
    • intravascular deposition of immune complexes in glomeruli
    • formation of immune complexes on self-antigens on glomerular basement membrane

presnetation of SLE

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6
Q

LN dx

A
  • persistent proteinuria and/or cellular casts
  • renal biopsy and histology to confirm
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7
Q

LN presentation

A
  • foamy urine
  • peripheral edema
  • concomitant HTN
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8
Q

topical steroids in SLE

A
  • lower potency for face
  • using it around the clock makes it lose its efficacy
  • can use a topical CNI if topical steroid CI
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9
Q

adequte HCQ trial in SLE

A

6 months

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10
Q

HCQ in SLE

A
  • give to everyone
  • reduces flares and reduces risk of major organ involvemnt
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11
Q

gluocortivoid use in SLE

A
  • Adjunctive treatment for
    • Moderate-severe flare
      • Rapid symptom relief: prednisone 20-60mg/day or IV pulse followed by PO taper
        • Taper down by 10-20% Q 5-7 D
    • organ or life threating
    • inadequater response to hydroxychloroquine or NSAIDs
  • Poor QOL without
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12
Q

GLutocorticoid lonog term use AE

A
  • OP
  • HLD
  • Fat redistribution
  • Moon facies
  • Growth faillure
  • Amenorrhea
  • Immunsuppresion
  • HPA suppression
  • Cataracts
  • Obesity
  • Seziures
  • Echymosis
  • Muscle weakness
  • Acne
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13
Q

Belimumab use in SLE

A
  • b lymphocyte stimulat antag
  • adjunctive treatment for
    • non-active-CNS, Ab (+) SLE
    • musculoskeletal cutaneous disease unresponsive to HCQ, NSAID, steroid
    • lupus nephritis III, IV, or V
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14
Q

belimumab AE

A
  • nausea
  • diarrhea
  • allergic reaction
  • ifusion reaction
  • depression/suicidality
  • PML
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15
Q

anifrolumab use in SLE

A
  • interferon antag → reuce imune cell recruitment, improves symptoms, stabilizes organ disease
    • Adjunct med to be used in combo with standard SLE treatment
    • IV inf Q4W
    • NOT indicated in active LN or CNS disease
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16
Q

When to use immunosuppressants in SLE and list them

A
  • for poor symptom control refractory to HCQ/NSAID/steroid
  • indicated for organ threatening LE (lupus nephritis
  • immunosuppressants
    • MTX
    • AZA
    • MMF
    • CYC (cyclophsophamide)
    • Cyclosporine
    • rituximab
    • CNIs (tacrolimus)
    • Voclosporin
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17
Q

MTX use inSLE

A

If pt also has RA or primary presentaiton of arhtritis

18
Q

AZA use in SLE

A
  • Second line after steroids for a more moderate disease coures
  • Safe in preggers
19
Q

AZA AE

A
  • Bone marrow suppresion
  • N/V
20
Q

MMF use in SLE

A
  • For proliferative (II-IV) LN and is second line for membranous (V) LN
    • Better than cyclophosphamide

Also used in non-renal disease (non LN)
Not really effective in neuropsychiatric disease

21
Q

MMF AE

A
  • Diarrhea
  • Abdoimal pain
  • Anorexia
  • Nausea
  • Hematologic
  • CV
  • Teratogenicty → no preggers
22
Q

CYC use in SLE

A

Used for organ-threatening cardiopulmonary, renal or neuropsych disease

23
Q

CYC AE

A

TOXIC
- Hematologic tox
- Cardio tox
- neurologic to
- Permanent infertility

24
Q

Cyclosporine use in SLE

A
  • Used for membranous (V) LN
  • Approximately same effectivness as CYC but less tox
25
Q

Cyclosporine AE

A
  • HTN
  • Hematologic tox
  • Nephrotox
  • Neurologic tox
26
Q

Rituximab use in SLE

A
  • really last resort
  • Off label use in pts with severe renal, hematologic or neurpsych SLE refractory to other agents
    • Failure of MMF/CYC in LN or relapsing disease
27
Q

PO tacrolimus use in SLE

A

For plroferative (V) L alone or in combo with MMF

28
Q

Voclosporin use in SLE

A
  • PO CNI → decreases cytokine production and lymphocyte proliferation
  • In adjunct to one of the
    immunosuppresants in active lupus nephritis
  • Do NOT use with CYC
  • CYP 3A4 interactions
29
Q

Voclosporin AE

A
  • BBW: infections adn malignances
  • Nephrotoxic if eGFR <45
30
Q

SLE treat to target principles

A
  • Shared decisions between pt and MD
  • Prolong survival
  • Minimize organ damage
  • Improve QOL
  • SLE may require multidisciplinary
  • Monitor, f/u and adjust
31
Q

SLE treat to target recommendations

A
  • Remissio or reduced disease
  • Flare prevention is a realisitic goal
  • do NOT have to escalate treatment in asymptomatic pts with stable or increaseing serological activity
  • Prevent dmaage accrual
  • Pay attention to QOL
  • Recognize and treat LN early
  • Optimize LN outcomew with 3 yrs of immunosuppressive therapy after induction
  • Lowest posible dose of steroid
  • Pay attention to APS
  • Consider antimalarials
  • Supportive treatments for toehr disease states PRN
32
Q

SLE nonpharm

A
  • Sunscreen
  • Avoid photosensitizing agents, stress, smoking
  • Immunizations, vaccines
33
Q

SLE skn disease first line agents

A
  • Topicals: steroids, topical CNIs
  • HCQ
34
Q

SLE skn disease refractory agents

A
  • systemi steroids: preferred agent if first line isn’t enough
  • methotrexate
  • MMF
  • belimumab
  • anifrolumab
  • retinoids
  • dapsone
35
Q

Rfractory/severe SLE agents

A
  • Steroid -sparing immunosuppresnats
    • methotrexate
    • MMF
    • azathioprine: for preggers
    • cyclophosphamide in organ-threatening idsease
  • Other
    • belimumab
    • anifrlumab
36
Q

Non-SLE/LN speific tratment that neds to be considered in these pts

A
  • IF pt has glomerular disease (persistant proteinuria and/or HTN): ACE or ARB
  • IF pt has LDL >100: statin
37
Q

Class III-IV (proliferative LN) treatment

A
  • Initial optiosn
    • glucocorticoid + MMF OR
    • glucocorticoid + low dose IV CY OR
    • glucocorticoid + MMF + TAC
  • If pt responds with 3-12 months, de-escalate to MMF or AZA
  • IF pt does NOT respond: switch to alternative induction therapy or add TC to MMF or rituximab
38
Q

Class V (membranous LN) treatment

A
  • Initial options
    • UPr <3: RAAS blockade (consider GC + MMF)
    • UPr > 3: RAAS blockde AND GC + MMF
  • If pt responds with 3-12 months, de-escalate to MMF or AZA
  • IF pt does NOT respond: IV CY or CNI
    • If still no response:
      • CNI monotherapy or add on to MMF OR
      • high dose IV CY OR
      • rituximab
39
Q

If preggers and active LN

A
  • Continue HCQ if already on
  • non-fluorinated PO GC
  • AZA (MDD 2mg/kg) if necessary
  • consider pre-term delivery if LN real bad@28wks
40
Q

APL (+) with no event treatment

A
  • baby asa QD
  • if preggers: can consider adding LMWH
41
Q

APS treatment

antiphospholipid syndrome

A
  • warfarin
    • if arterial, goal INR: 3-4
    • if venous, goal INR: 2-3

PHM 702: Pulm and ToXXX (14 decks)

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