Steriods & Autoimmune Conditions Flashcards

1
Q

When are steroids used?

A

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

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2
Q

What steroid mimics Aldosterone?

A

Fludrocortisone

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

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3
Q

Long-Term Effects of Steroids

A

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

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4
Q

Cushing Syndrome

A

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.

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5
Q

Ways to Reduce Systemic Steroid Risk

A

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

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6
Q

Systemic Steroids Dose Equivalency

A

[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

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7
Q

What are the Glucocorticoids?

A

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

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8
Q

Short-term side effects of Glococorticoids

A

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

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

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9
Q

Immunosuppression from Steriods

A

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

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10
Q

How to taper Steriods?

A

Reduce dose by 10-20% every few days

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11
Q

What are the lab test which indicates an Autoimmune Condition?

A

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

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12
Q

Risks of Strong Immunosuppressants (used to treat autoimmune conditions)

A

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

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13
Q

What is Rheumatoid Arthritis?

A

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

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14
Q

Treatment for Rheumatoid Arthritis

A

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.

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15
Q

Methotrexate

A

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

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16
Q

Hydroxychloroquine

A

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

17
Q

Sulfasalazine

A

Brand: Azulfidine

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

18
Q

JAK Inhibitors

A

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

19
Q

Anti-TNF Biologic DMARDs used for Rheumatoid Arthritis

A

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

20
Q

Anti-TNF Biologic DMARDs

A

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

21
Q

Non-TNF Biologic DMARDs

A

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

22
Q

What is Systemic Lupus Erythematosus?

A

-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

23
Q

Lab Test for Lupus

A

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

24
Q

Key Drugs that can cause DILE

A

My Pretty Pony Miss Muffin The Queen Is A Terrific Horse

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

25
Drug Treatment of Lupus
1) Steroids 2) Hydroxychloroquine (Plaquentil) 3) Cyclophosphamide, Azathioprine, Mycophenolate, Cyclosporine 3) Belimumab (Benlysta)
26
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
27
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
28
Drug of Choice in MS
Glatiramer acetate (Copaxone) -Activates T-lymphocyte suppressor cells -Drug of choice in pregnancy -SQ
29
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
30
What is Celiac Disease?
This is an immune response to eating gluten Clinical Presentation: -Diarrhea -Abdominal Pain -Bloating -Weight Loss Treatment: -Avoid gluten
31
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)
32
What is Psoriasis?
Red patches, raised with a silvery white buildup Non-Drug Treatment: -UV Light -Phototherapy or laser light therapy
33
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)