Steroids and Autoimmune Conditions Flashcards

1
Q

HPI: CY is a 38 y/o female who presents to the hospital on 7/7 with a severe flare of rheumatoid arthritis. She’s taken multiple agents in the past including: gold, MTX, prednisone, infliximab (progressed on med), and etanercept. She’s here for a clinic visit and was found to have an acute episode of hepatitis and unusual bruising.

Allergies: Etanercept (severe rash, swelling)

CY has had an allergic reaction to etanercept. What drug class does etanercept belong to?

a. Anti-CD 20
b. Folate antagonist
c. Interferon inhibitor
d. Interleukin inhibitor
e. Tumor necrosis factor inhibitor

A

e

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2
Q

HPI: CY is a 38 y/o female who presents to the hospital on 7/7 with a severe flare of rheumatoid arthritis. She’s taken multiple agents in the past including: gold, MTX, prednisone, infliximab (progressed on med), and etanercept. She’s here for a clinic visit and was found to have an acute episode of hepatitis and unusual bruising.

PMH: Allergic rhinitis, GERD, osteopenia, fibromyalgia, breast cancer (R breast lumpectomy)

Meds:
Leflunomide 20 mg QD
MTX 2.5 mg, 10 tabs weekly
Prednisone 2.5 mg QD
Pantoprazole 40 mg QD
Loratadine 10 mg QD PRN
Capsaicin apply 5x daily
Lidocaine 5% ointment PRN

Labs on 5/17:
WBC (4-11) = 5.9
GLU = 135
AST (10-35) = 35
ALT (6-40) = 39

Labs on 7/7:
WBC = 5.6
GLU = 131
AST = 212
ALT = 199

Which of CY’s meds are most likely contributing to the new lab abnormalities on 7/7?

a. Leflunomide
b. Methotrexate
c. Prednisone
d. Pantoprazole
e. Lidocaine

A

a, b

Both leflunomide and MTX can cause acute hepatitis.

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3
Q

HPI: CY is a 38 y/o female who presents to the hospital on 7/7 with a severe flare of rheumatoid arthritis. She’s taken multiple agents in the past including: gold, MTX, prednisone, infliximab (progressed on med), and etanercept. She’s here for a clinic visit and was found to have an acute episode of hepatitis and unusual bruising.

Meds:
Leflunomide 20 mg QD
MTX 2.5 mg, 10 tabs weekly
Prednisone 2.5 mg QD
Pantoprazole 40 mg QD
Loratadine 10 mg QD PRN
Capsaicin apply 5x daily
Lidocaine 5% ointment PRN

CY tells the medical team that she wants to start trying to get pregnant after her recovery. Which of her meds is contraindicated in pregnancy?

a. Leflunomide
b. Pantoprazole
c. Methotrexate
d. Loratadine
e. Prednisone

A

a, c

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4
Q

A pt reports that her mouth and gums are sore. Upon inspection, the oral cavity appears inflamed. Which med is most likely responsible for this complaint?

a. Hydroxychloroquine
b. Methotrexate
c. Infliximab
d. Rituximab
e. Interferon beta-1a

A

b

When used weekly for rheumatoid arthritis, the most common side effects of methotrexate are stomatitis (inflammation and redness of the oral mucosa that can lead to pain and difficulty talking, eating, and sleeping), nausea, and diarrhea.

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5
Q

Which steroid is preferred for managing orthostatic hypotension in a pt with Addison’s disease?

a. Prednisone
b. Dexamethasone
c. Hydrocortisone
d. Fludrocortisone
e. Cortisone

A

d

-Fludrocortisone has mineralocorticoid activity. It mimics aldosterone and helps maintain fluid and electrolyte balance, which helps stabilize BP.
-Addison’s disease occurs when the body isn’t producing enough cortisol or when exogenous steroids are stopped abruptly (in this case, the pt may experience an Addisonian Crisis).

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6
Q

HPI: OP is a 54 y/o male who presents to the clinic today with increased pain and stiffness. He’s also complaining of GI upset from his Trexall. His provider confirms disease progression of his rheumatoid arthritis.

PMH: T2DM, HTN, rheumatoid arthritis, G6PD deficiency

Meds:
Trexall 20 mg PO weekly
Millipred 10 mg PO daily
Lotensin 40 mg PO daily
Lantus 20 mg SC QHS

What additional med/s would be appropriate to add for improved control of OP’s rheumatoid arthritis?

a. Methotrexate
b. Humira
c. Infliximab
d. Benlysta
e. Rituximab

A

b, c, e

-Methotrexate is a duplication of therapy (the pt is already taking Trexall)
-Benlysta is not indicated for the tx of rheumatoid arthritis

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7
Q

HPI: OP is a 54 y/o male who presents to the clinic today with increased pain and stiffness. He’s also complaining of GI upset from his Trexall. His provider confirms disease progression of his rheumatoid arthritis.

PMH: T2DM, HTN, rheumatoid arthritis, G6PD deficiency

Meds:
Trexall 20 mg PO weekly
Millipred 10 mg PO daily
Lotensin 40 mg PO daily
Lantus 20 mg SC QHS

What other med should OP be taking because he’s on Trexall?

a. Vitamin B12
b. Vitamin B6
c. Glucarpidase
d. Aspirin
e. Folic acid

A

e

-MTX inhibits dihydrofolate reductase, interfering with folate metabolism. Folate depletion contributes to several AEs of MTX, including GI symptoms and liver toxicity.
-Leucovorin may be used as an alternative folic acid to decrease MTX-induced AEs.

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8
Q

A pt is about to receive an intravenous infusion of a drug for tx of rheumatoid arthritis. The drug is only stable in normal saline and requires a filter. Which drug is described?

a. Infliximab
b. Adalimumab
c. Certolizumab
d. Rituximab
e. Sarilumab

A

a

-Both infliximab and rituximab are IV infusions that can cause infusion-type reactions (chills, fever, pruritus, hypotension); pre-medication may be necessary.
-Another product that’s available IV and requires a filter is golimumab.

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9
Q

Which of the following should be checked prior to initiating TNF-inhibitor therapy?

a. Sodium
b. TB test
c. Pulmonary function tests
d. 24-hour urine collection
e. HBV tests

A

b, e

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10
Q

The pharmacist is dispensing etanercept injection to a pt who hasn’t used this med previously. How should the pt be counseled to inject this med?

a. SC once daily
b. IM once weekly
c. IM once daily
d. SC once weekly
e. SC once monthly

A

d

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11
Q

What is a 1st line tx for Raynaud’s phenomenon?

a. Angiotensin receptor blockers
b. Phosphodiesterase inhibitors
c. Calcium channel blockers
d. ACE inhibitors
e. Statins

A

c

CCBs, such as ER nifedipine, are often used 1st line to manage Raynaud’s phenomenon.

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12
Q

CM is a 35 y/o female presenting with fatigue, arthralgia, and a butterfly rash over the bridge of her nose. She has been diagnosed with SLE. Which counseling point should the pharmacist provide to CM?

a. Avoid exercise, which may exacerbate arthralgias.
b. Smoking is protective for this disease; wear a nicotine patch to prevent flares.
c. Liver damage is the primary complication of SLE.
d. Avoid prolonged exposure to the sun to reduce photosensitivity.
e. Avoid citrus foods as they have been shown to trigger the disease.

A

d

-The main complications are renal (> 50% of pts develop lupus nephritis), hematologic, and neurologic.
-Photosensitivity is common d/t the condition.

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13
Q

Which of the following meds can cause yellow-orange urine discoloration?

a. Methotrexate
b. Teriflunomide
c. Tofacitinib
d. Sulfasalazine
e. Dimethyl fumarate

A

d

Sulfasalazine can cause yellow-orange discoloration of the urine or skin.

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14
Q

HPI: EW is a 51 y/o male who comes to the clinic with complaints of severe pain and swelling in his fingers, toes, and wrists. He states his other joints are “achy,” and he has stiffness in the morning that makes it difficult for him to get going. He had joint pain for the past 3 months, but the intensity has become much worse.

PMH: COPD, HTN, depression, erectile disfunction

Social hx: Denies EtOH use, stopped smoking 2 years ago

Rheumatoid factor (< 40 IU/mL) = 90

Which of the following is consistent with a diagnosis of rheumatoid arthritis in EW?

a. Positive rheumatoid factor
b. Swollen, painful joints
c. Depression
d. Morning stiffness
e. Smoking history

A

a, b, d

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15
Q

HPI: EW is a 51 y/o male who comes to the clinic with complaints of severe pain and swelling in his fingers, toes, and wrists. He states his other joints are “achy,” and he has stiffness in the morning that makes it difficult for him to get going. He had joint pain for the past 3 months, but the intensity has become much worse.

Allergies: Sulfa (rash)

Rheumatoid factor (< 40 IU/mL) = 90

EW is diagnosed with rheumatoid arthritis. Which of the following meds should be started to reduce disease progression?

a. Prednisone
b. Methotrexate
c. Cimzia
d. Sulfasalazine
e. Simponi

A

b

-Pts with symptomatic RA should be started on a disease-modifying antirheumatic drug (DMARD).
-MTX should be used 1st line, if there are no contraindications, for treating RA.
-Sulfasalazine should be avoided in pts with a sulfa allergy.

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16
Q

A pt using methotrexate for rheumatoid arthritis should receive which of the following instructions from the pharmacist concerning the dosing schedule?

a. Taken weekly
b. Taken daily
c. Taken monthly
d. Only used when you have an acute flare
e. Only available in an oral tablet

A

a

-MTX is dosed weekly for pts with RA; taking it daily can result in serious side effects.
-Oral, SC, and IM forms of MTX are available.

17
Q

A pt is receiving Humira. Choose the correct statement/s regarding Humira:

a. It’s injected IV once weekly
b. Live vaccines can be given to pts using Humira
c. The generic name is adalimumab
d. It can be administered in combo with MTX
e. It can be administered in combo with infliximab

A

c, d

-Administered SC every OTHER week
-Biologic DMARD: Can’t be used with other biologic DMARDs
-Pts receiving biologic immunosuppressant drugs shouldn’t receive live vaccines during tx (they must be given before the start of therapy)

18
Q

A pt has had an acute exacerbation of her RA. The Dr has prescribed a short course of PO prednisone. Short-term side effects that can occur from the use of PO steroids include:

a. Depression
b. Moon face
c. Glaucoma
d. Irritability
e. Muscle wasting

A

d

All other AEs shown are Cushingoid symptoms d/t long-term use.

19
Q

MA recently visited her healthcare provider and was diagnosed with Raynaud’s. What is the classic symptom of Raynaud’s?

a. HTN
b. Cold, blue fingers and toes
c. Photosensitivity
d. Chest pain
e. Migraines

A

b

Raynaud’s is caused by vasospasm triggered by cold or stress. The classic symptom is white, then blue fingers and toes that become painful upon warming.

20
Q

BM will begin Plaquenil therapy for RA. Which of the following will need to be monitored routinely?

a. CD4 count
b. Eye exam
c. Hearing exam
d. Urinalysis
e. Chest x-ray

A

b

Visual problems, including irreversible retinopathy, are a concern with the use of hydroxychloroquine. Eye exams should be monitored at baseline and every 3 months.

21
Q

RK presents to the clinic for a routine follow-up visit. He states that he’s not happy injecting so frequently.

PMH: S/P MI 2 years ago, multiple sclerosis

Meds:
Interferon beta-1a 44 mcg SC 3x weekly
Pantoprazole 40 mg QD
Lopressor 50 mg BID
Prinivil 10 mg QD
Zocor 40 mg QD

Which of the following meds can be interchanged for RK’s interferon therapy to decrease the burden of injections?

a. MTX
b. Interferon beta-1b
c. Oral interferon
d. Peginterferon beta-1a
e. Glatiramer acetate

A

d

Peginterferon beta-1a (Plegridy) is an interferon beta form that’s given every 14 days.

22
Q

JS is being treated in the hospital for an acute RA exacerbation with dexamethasone 3 mg PO BID. The Dr would like to transition JS to an equipotent dose of prednisone. What is the equipotent daily dose of prednisone?

a. 60 mg
b. 50 mg
c. 40 mg
d. 20 mg
e. 10 mg

A

40

Look at the steroid conversion chart.

23
Q

A pt with RA wishes to begin therapy with adalimumab. She was tested for tuberculosis. The skin test was positive, but her chest x-ray was negative. She’s diagnosed with latent TB infection. Choose the correct statement:

a. She has latent TB; no tx is required.
b. She will need to begin latent TB tx prior to starting adlimumab.
c. She has a contraindication to adalimumab therapy.
d. She will require etanercept therapy instead d/t her positive TB skin test.
e. She should be put in isolation until her TB skin test is negative.

A

b

24
Q

AK is prescribed Copaxone for his condition. Which of the following statements is true?

a. This med is given weekly.
b. AK has psoriasis.
c. Common side effects include sweating and dyspnea.
d. This med is contraindicated in pregnancy.
e. The generic name is tolcapone.

A

c

-Glatiramer acetate (Copaxone) is used for MS and can cause injection-site reactions, flushing, sweating, pain, chest pain, dyspnea, and rash.
-It’s administered by SC injection daily or 3x per week and is the preferred tx of MS during pregnancy.

25
Q

Which of the following lab values would suggest a diagnosis of systemic lupus erythematosus?

a. Positive ANA (antinuclear antibodies)
b. Positive RF (rheumatoid factor)
c. Low C-peptide
d. Low CRP (c-reactive protein)
e. High ACPA (anti-citrullinated peptide antibody)

A

a

-c-peptide is used to determine insulin production in pts with diabetes
-RF and ACPA are tests used in the diagnosis of RA
-CRP is a non-specific inflammatory marker. It would be elevated in SLE

26
Q

Rank the follow PO corticosteroids in order of their anti-inflammatory potency.

a. Dexamethasone
b. Methylprednisolone
c. Cortisone
d. Prednisone
e. Hydrocortisone

A

c, e, d, b, a

27
Q

A pt with a severe RA exacerbation is prescribed a short course of steroid using the Medrol tablet therapy pack. Choose the correct statement:

a. Therapy packs provide a convenient tapering system for the pt, which decreases the risk for side effects.
b. PO steroids can cause many problems, including hypoglycemia, dehydration, and hypotension.
c. Medrol contains methylprednisone, which is a prodrug of prednisolone.
d. A dose pack contains a variety of strengths of the drug, so a taper can be easily managed by the pt.
e. An alternative brand name for this dose pack is Solu-Medrol.

A

a

28
Q

Celiac disease is an immune response to gluten. Which of the following contain gluten?

a. Oats
b. Wheat
c. Barley
d. Rye
e. Rice

A

b, c, d

29
Q

A pt was taking a steroid without a taper for 4 weeks. He would be considered to be immunosuppressed if the regimen was:

a. Hydrocortisone 20 mg PO BID
b. Methylprednisolone 12 mg PO TID
c. Prednisolone 10 mg PO daily
d. Dexamethasone 1.5 mg PO daily
e. Cortisone 50 mg PO daily

A

b

A pt is immunosuppressed when using 20 mg/day or greater of prednisone or prednisone equivalent. Look at steroid equivalent chart.

30
Q

Which of the following meds can be used to treat systemic lupus erythematosus?

a. Etanercept
b. Glatiramer acetate
c. Abciximab
d. Hydroxychloroquine
e. Isoniazid

A

d

Isoniazid can cause SLE.

31
Q

A pt is being started on fingolimod for MS. What is the most important monitoring parameter with initial use of this med?

a. Respiratory rate
b. Heart rate
c. Pain score
d. Serum creatinine
e. Cholesterol

A

b

-Bradycardia is the main concern with this drug; an ECG is required at baseline and any time treatment is interrupted. HR should be monitored for 6 hours after the first dose.
-Other major side effects requiring monitoring include macular edema, hepatotoxicity, and myelosuppression.

32
Q

Calcipotriene is a dermatological drug that’s used for this condition:

a. Psoriasis
b. Acne
c. Raynaud’s
d. Sjogren’s syndrome
e. Lupus

A

a

33
Q

KB has RA and has been using prednisone 20 mg PO daily for 2 years. She believes it may be possible to stop the prednisone, as she’s having a good response to methotrexate. Choose the correct statement concerning her prednisone:

a. She should remain on the prednisone indefinitely.
b. She’ll require a slow taper in order to d/c the prednisone.
c. She’s on a low dose and doesn’t need a taper.
d. She’s not at risk for significant side effects since she’s on a low dose.
e. The prednisone should be continued to counteract some of the immunosuppressive effects of methotrexate.

A

b

34
Q

HN is a 44 y/o female who comes to the clinic with complaints of a red rash over the bridge of her nose. The rash isn’t painful. She has been taking the following meds for the past 2 years: omeprazole, aspirin, hydrochlorothiazide, hydralazine, atorvastatin, and sertraline. Which of HN’s meds is most likely to be causing her rash?

a. Aspirin
b. HCTZ
c. Hydralazine
d. Atorvastatin
e. Sertraline

A

c

Drugs that can cause drug-induced lupus erythematosus (DILE): My Pretty Malar Marking Probably Has A TransIent Quality
-Methimazole
-Propylthiouracil
-Methyldopa
-Minocycline
-Procainamide
-Hydralazine (alone and in BiDil)
-Anti-TNF agents
-Terbinafine
-Isoniazid
-Quinidine

35
Q

ML is a 31 y/o female with a recent diagnosis of rheumatoid arthritis. She hasn’t wanted to start any med. She’s at clinic today with complaints of severe pain in her joints, weakness, extreme fatigue, and she’s crying. She reports episodes of N/V in the last 3 days.

Allergies: Sulfa

Labs: hCG +

ML now wants to start tx. Which of the following meds can be recommended at this time?

a. Adalimumab
b. Remicade
c. Rituxan
d. Sulfasalazine
e. Methotrexate

A

a

-ML is pregnant and shouldn’t use any meds that can harm the fetus (e.g., MTX).
-Riuxan (rituximab) and Remicade (infliximab) must be used in combo with MTX.
-ML has an allergy to salicylates, so sulfasalazine is inappropriate.

36
Q
A

a, c, e