Steriods & Autoimmune Conditions

Question 1

When are steroids used?

Answer 1

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

Question 2

What steroid mimics Aldosterone?

Answer 2

Fludrocortisone

-FDA approved for Addison’s Disease
-Off label for Orthostatic Hypotension (since it mimics aldosterone to retain sodium and water)

Question 3

Long-Term Effects of Steroids

Answer 3

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

Question 4

Cushing Syndrome

Answer 4

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.

Question 5

Ways to Reduce Systemic Steroid Risk

Answer 5

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

Question 6

Systemic Steroids Dose Equivalency

Answer 6

[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

Question 7

What are the Glucocorticoids?

Answer 7

Cortisone, Hydrocortisone, Prednisone, Prednisolone, Methylprednisolone, Triamcinolone, Dexamethasone, Bethamethasone

Question 8

Short-term side effects of Glococorticoids

Answer 8

Worsening of:
-Diabetes
-HTN
-Glaucoma
-Psych conditions

-Increase in appetite/weight gain
-Emotional instability
-Insomnia

Question 9

Immunosuppression from Steriods

Answer 9

Prednisone
>= 2 mg/kg/day OR
>= 20 mg/day
> 2 weeks

Question 10

How to taper Steriods?

Answer 10

Reduce dose by 10-20% every few days

Question 11

What are the lab test which indicates an Autoimmune Condition?

Answer 11

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

Question 12

Risks of Strong Immunosuppressants (used to treat autoimmune conditions)

Answer 12

1) Reactivation of TB and HepB & C
2) Lymphomas and skin cancers
3) Infections

Question 13

What is Rheumatoid Arthritis?

Answer 13

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

Question 14

Treatment for Rheumatoid Arthritis

Answer 14

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.

Question 15

Methotrexate

Answer 15

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

Question 16

Hydroxychloroquine

Answer 16

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

Question 17

Sulfasalazine

Answer 17

Brand: Azulfidine

-Methotrexate and Hydroquloroquine is preferred over this.
-Sulfa Allergy, Salicylate Allergy (e.g. Aspirin Allergy)
-Orange skin/urine

Question 18

JAK Inhibitors

Answer 18

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

Question 19

Anti-TNF Biologic DMARDs used for Rheumatoid Arthritis

Answer 19

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

Question 20

Anti-TNF Biologic DMARDs

Answer 20

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

Question 21

Non-TNF Biologic DMARDs

Answer 21

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

Question 22

What is Systemic Lupus Erythematosus?

Answer 22

-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

Question 23

Lab Test for Lupus

Answer 23

1) Anti-nuclear Antibodies (ANA)
2) Anti-SSDNA and Anti-dsDNA

Question 24

Key Drugs that can cause DILE

Answer 24

My Pretty Pony Miss Muffin The Queen Is A Terrific Horse

Methimazole
Procainamide
Propylthiouracil
Methyldopa
Minocycline
Quinidine
Isoniazid
Anti-TNF agents
Terbinafine
Hydralazine

Question 25

Drug Treatment of Lupus

Answer 25

1) Steroids
2) Hydroxychloroquine (Plaquentil)
3) Cyclophosphamide, Azathioprine, Mycophenolate, Cyclosporine
3) Belimumab (Benlysta)

Question 26

Multiple Sclerosis

Answer 26

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

Question 27

Treatment for Multiple Sclerosis

Answer 27

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

Question 28

Drug of Choice in MS

Answer 28

Glatiramer acetate (Copaxone)

-Activates T-lymphocyte suppressor cells
-Drug of choice in pregnancy
-SQ

Question 29

What is Raynaud’s Phenomenon?

Answer 29

-Decreased blood flow to the fingers
-Cold or stress can trigger vasospasm or the small blood vessels

DOC: Nifedipine or another CCB

Question 30

What is Celiac Disease?

Answer 30

This is an immune response to eating gluten

Clinical Presentation:
-Diarrhea
-Abdominal Pain
-Bloating
-Weight Loss

Treatment:
-Avoid gluten

Question 31

What is Sjogren’s Syndrome?

Answer 31

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)

Question 32

What is Psoriasis?

Answer 32

Red patches, raised with a silvery white buildup

Non-Drug Treatment:
-UV Light
-Phototherapy or laser light therapy

Question 33

Drug Treatment for Psoriasis

Answer 33

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)