Steriods & Autoimmune Conditions Flashcards
When are steroids used?
1) Inflammatory Conditions (Rheumatoid arthritis, psoriasis, acute asthma exacerbation)
2) Immune suppression post transplant
3) Adrenal Insufficiency - replacement of steroids that the adrenal gland is not producing in adequate amounts
What steroid mimics Aldosterone?
Fludrocortisone
-FDA approved for Addison’s Disease
-Off label for Orthostatic Hypotension (since it mimics aldosterone to retain sodium and water)
Long-Term Effects of Steroids
Systemic steroids can cause the adrenal gland to stop producing cortisol due to feedback inhibition.
-It causes HPA (Hypothalamic-Pituitary-Adrenal) Axis Suppression
-This is why we have to taper the dose slowly when we come off of steroids - we can give our body time to make cortisol again
-Glaucoma, Cataract
-Fat deposit on face, abdomen and upper back
-Purple-Pink stretch marks on abdomen, thighs, breasts and arms
-Growth retardation
-Infection; impaired healing
-Poor bone health
-Diabetes
-GI bleeding
-Acne
-Psych changes (anxiety, depression, delirium, psychosis)
-Hypothyroidism
Women Only: Hair growth on face and body, Irregular or absent periods
Cushing Syndrome
This is when the adrenal gland makes too much cortisol, or if there is higher-than-normal doses of steriods
-Addison’s disease is the opposite: the adrenal gland is not making enough cortisol!
-If exogenous steroids are stopped suddenly, it can cause “Addisonian Crisis”. This is characterized as volume depletion and hypotension which can be fatal.
Ways to Reduce Systemic Steroid Risk
1) Use alternative day dosing - this decreases Cushing-like Syndrome
2) For joint inflammation, inject into the joint so the drug stays local
3) For a condition in the gut, use a steroid with low systemic absorption, such as budesonide
4) Asthma: use inhaled steroids that mostly stay in the lungs
5) Use the lowest possible dose for the shortest possible time
Systemic Steroids Dose Equivalency
[Least potent to Most potent] IV & PO
Cute Hot Pharmacists and Physicians Marry together & Deliver Babies
Cortisone - 25 mg
Hydrocortisone - 20 mg
Prednisone -5 mg
Prednisolone - 5 mg
Methylprednisolone - 4 mg
Triamcinolone - 4 mg
Dexamethasone - 0.75 mg
Betamethasone - 0.6 mg
What are the Glucocorticoids?
Cortisone, Hydrocortisone, Prednisone, Prednisolone, Methylprednisolone, Triamcinolone, Dexamethasone, Bethamethasone
Short-term side effects of Glococorticoids
Worsening of:
-Diabetes
-HTN
-Glaucoma
-Psych conditions
-Increase in appetite/weight gain
-Emotional instability
-Insomnia
Immunosuppression from Steriods
Prednisone
>= 2 mg/kg/day OR
>= 20 mg/day
> 2 weeks
How to taper Steriods?
Reduce dose by 10-20% every few days
What are the lab test which indicates an Autoimmune Condition?
1) ESR - Erythrocyte Sedimentation Rate
2) CRP - C-reactive Protein
3) RF - Rheumatoid Factor
4) ANA - Anti-nuclear Antibody
*These tests are non-specific: they do not indicate one type of disease.
*Specific symptoms will help to differentiate which autoimmune disorder it is
Risks of Strong Immunosuppressants (used to treat autoimmune conditions)
1) Reactivation of TB and HepB & C
2) Lymphomas and skin cancers
3) Infections
What is Rheumatoid Arthritis?
Chronic condition, primarily affecting the joints
*Clinical Presentation:
-Bilateral, symmetrical (unique to RA): Osteoarthritis is unilateral
-Joint swelling
-Pain
-Stiffness
-Deformity
*Lab Test:
-RF
-ACPA (Anti-citrullinated peptide antibody) <—Specific for RA
Treatment for Rheumatoid Arthritis
DMARDs - Disease-modifying Antirheumatic Drugs
First Line: Methotrexate (non-biologic DMARD)
*If the patient still has moderate to high disease activity while on Methotrexate, use:
1) Combination treatment of non-biological DMARD
2) TNF Inhibitor (Biologic)
3) Non-TNF Biologic
*NEVER use 2 biologics together
-Low dose steroid (defined as <= 10 mg Prednisone or equivalent) can be added at the starting of therapy for bridging. DMARDs take a while to start working.
Methotrexate
Brand: Trexall, Rasuvo, Otrexup
MOA: Inhibits dihydrofolate reductase enzyme
-Low WEEKLY doses (PO, SQ, IM)
-Boxed Warning: Hepatotoxicity, myelosuppression, mucositis/stomatitis, pregnancy
-Side Effects: Increased LFTs, Stomatitis, Alopecia
-Give folic acid supplementation on the day after MTX, to decrease side effects
Hydroxychloroquine
Brand: Plaquenil
-Non-biologic DMARD
-Can be used alone or with Methotrexate
-Commonly used as an alternative to Methotrexate in patients with liver disease
-Warning: Irreversible retiopathy
-Take with food or milk
Sulfasalazine
Brand: Azulfidine
-Methotrexate and Hydroquloroquine is preferred over this.
-Sulfa Allergy, Salicylate Allergy (e.g. Aspirin Allergy)
-Orange skin/urine
JAK Inhibitors
1) Tofacitinib (Xeljanz)
2) Baricitinib (Olumiant)
3) Upadacitinib (Rinvoq)
MOA: Inhibits janus kinase enzymes (JAK), which stimulates immune cell function
-Rheumatoid Arthritis non-biologic DMARD
Boxed Warnings: Serious Infections including TB, Increased risk of malignancies and thrombosis
*DO NOT USE with biologic DMARDs or potent immunosuppressants
Anti-TNF Biologic DMARDs used for Rheumatoid Arthritis
1) Etanercept (Enbrel) +-MTX
-SQ weekly
2) Adalimumab (Humira) +-MTX
-SQ every other week
3) Infliximab (Remicade) +MTX
-IV, use with methotrexate
-NS only!
4) Certlizumab pegol (Cimzia) +-MTX
-SQ every other week
5) Golimumab (Simponi) +MTX
-SQ monthly
Anti-TNF Biologic DMARDs
Boxed Warnings: Serious infections, lymphomas, malignancies
Warnings: Can cause demyelinating disease, HepB reactivation, Heart Failure, Hepatotoxicity, lupus-like syndrome
*DO NOT USE with other biologic DMARDs or live vaccines
Monitoring:
-Prior to starting, Test for TB, HepB
-Refrigeration is necessary
-Do not shake or freeze
Non-TNF Biologic DMARDs
Rituximab (Rituxan) IV
-Given with MTX
-Premedicate with steroid, acetaminophen, antihistamine required!
MOA: Binds to CD20 on B cells - which is believed to have a role in RA development and progression
Boxed Warnings:
-Infusion related reactions
-PML
-SJS/TEN
-HepB reactivation
What is Systemic Lupus Erythematosus?
-Common in females
-Common in AA and Asian population
Common Symptoms:
-Butterfly rash and red patches
-Kidney damage
-Anemia
-High blood pressure
Triggers:
-Sun exposure
-Drugs
-Viral Infections
Lab Test for Lupus
1) Anti-nuclear Antibodies (ANA)
2) Anti-SSDNA and Anti-dsDNA
Key Drugs that can cause DILE
My Pretty Pony Miss Muffin The Queen Is A Terrific Horse
Methimazole
Procainamide
Propylthiouracil
Methyldopa
Minocycline
Quinidine
Isoniazid
Anti-TNF agents
Terbinafine
Hydralazine
Drug Treatment of Lupus
1) Steroids
2) Hydroxychloroquine (Plaquentil)
3) Cyclophosphamide, Azathioprine, Mycophenolate, Cyclosporine
3) Belimumab (Benlysta)
Multiple Sclerosis
This is a chronic disease which attacks the myelin sheath
-More common in women 20-40 y.o
-Diagnosis: MRI
-Goal of Treatment: Prevent progression
Symptoms:
-Fatigue
-Weakness
-Numbness
-Blurred Vision
Treatment for Multiple Sclerosis
1) Glatiramer acetate (Copaxone) - First line
-Preferred in pregnancy
2) Interferon-beta formulations
-SQ
-Warnings: Psych conditions, injection site necrosis, increased LFT, thyroid dysfunction
-Do not expel air bubbles in prefilled syringes due to loss of dose
3) S1P Receptor Modulator (Fingolimod - mostly used oral formulation for MS)
-Monitored for at least 6 hours after the first dose with ECG
-CI in patients with CV disease or Stroke
-CI in pregnancy
4) Nuclear factor-like 2 activators (Dimethyl fumarate)
5) Monoclonal Antibodies or CHemo drugs (Last line)
-IV; given in clinic
Drug of Choice in MS
Glatiramer acetate (Copaxone)
-Activates T-lymphocyte suppressor cells
-Drug of choice in pregnancy
-SQ
What is Raynaud’s Phenomenon?
-Decreased blood flow to the fingers
-Cold or stress can trigger vasospasm or the small blood vessels
DOC: Nifedipine or another CCB
What is Celiac Disease?
This is an immune response to eating gluten
Clinical Presentation:
-Diarrhea
-Abdominal Pain
-Bloating
-Weight Loss
Treatment:
-Avoid gluten
What is Sjogren’s Syndrome?
This is an autoimmune disease characterized by severe dry eyes and dry mouth.
Dry Eyes Treatment:
-Artificial Tears
-Cyclosporine eye drops (Restasis)
-Lifitegrast (Xiidra)
Dry Mouth Treatment:
-Sugar-free gum or lozenges
-Antimicrobial moutwash rinse
-Saliva substitute
-Oral Muscarinic Agonists (Pilocarpine, Cevimeline)
What is Psoriasis?
Red patches, raised with a silvery white buildup
Non-Drug Treatment:
-UV Light
-Phototherapy or laser light therapy
Drug Treatment for Psoriasis
Topical:
-Steroids, Retinoids, Salicylic acid, coal tar
-Vitamin D analogues (Calcipotriene)
-Calcineurin inhibitors (Protopic, Elidel)
Systemic:
-Immunosuppressants (MTX, cyclosporine)
-Immunomodulators (Etanercept, Infliximab)
-PDE-4 Inhibitor (Otezla)
-Monoclonal antibodies (Stelara)
