Systemic Steroids and Autoimmune Flashcards
How is aldosterone replaced
via fludrocordisone which mimics it and has mineralcorticoid activity to balance waterand electrolytes
what disease is fludrocortisone used for for
addisons and orthostatic hypotension (off label)
glucocorticoid activity does what
anti-inflammatory
what do systemic steroids cause the adrenal gland to stop producing
cortisol, due to feedback inhibiton (HPA axis supression)
cushing’s syndrome
too much cortisol
addison’s disease
not enough cortisol
Steroid equivalence
Cute - cortisone 25 hot - hydrocortisone 20 pharmacists - prednisone 5 and physicians - prednisolone 5 marry - methylprednisolone 4 together - triamcinolone 4 and Deliver - dexamethasone 0.75 Babies - Betamethasone 0.6
Dexpak
dexamethason
decadron
dexamethasone
solu-cortef
hydrocortisone
medrol/solu-medrol
methylprednisolone
deltasone
prednisone
millipred
prednisolone
orapred
prednisolone
kenalog
triamcinolone
long term effects of steroids
1) fat deposits (moon face)
2) glaucoma/cataracts
3) stretch marks, bruising
4) growth retardation
5) infection, impaired wound healing
6) psychiatric changes
7) acne
8) gi bleds
9) diabetes
10) poor bone health
11) women - hairy, irregular periods
how to reduce systemic steroid risks
alternate day dosing, use steroid with low systemic absorption
short term systemic glucocorticoid side effects
insominia, weight gain, emotional instability and
can lead to: increased blood glucose (diabetes), increased blood pressure (hypertension), increased intraocular pressure (glaucoma)
warnings for systemic steroids
must taper slowly due to adrenal supression
common symptoms of autoimmune diseases
fatugue, weakness, pain
Tests that can detect inflammation
ESR (erythrocyte sedimintation rate), C-Reactive protein (CRP), rheymatoid factor (RF), anti-nuclear antibody (ANA)
steroid administration
with food
can you give live vaccines with people on steroids?
No if dose is high
What can the use of strong immunosuppressants increase the risk of
1) Reactivation of TB, Hep B/C - test prior to start
2) Viruses - give live vaccine before tx
3) Lymphomas and certain skin cancers
4) Infections
Rheumatoid arthritis symptoms
joint swelling, pain, stiffness, bone deformity
RA diagnosis
bilateral, symmetrical with joint pain worse after rest
lab tests to detect RA
ACPA (anti-citrullinated peptide antibody) and rheumatoid factor (RF)
when should RA be treated
if symptomatic should be started on DMARD (disease modifying RA drug) regardless of severity to prevent progression
Preferred initial tx for RA
methotrexate
what treatment combo should never be used IN RA
two biologic DMARDS due to risk of fatal infections
Trexall
Methotrexate
Plaquenil
Hydroxychloroquine
moa of MTX
irreversibly binds and inhibits dihydrofolate reductase, thus inhibiting folate
boxed warnings MTX
hepatotoxic, myelosupression, mucositis/stomatitis, pregnancy
monitoring MTX
CBC, LFTs, chest X Ray, hep B/S serology
warning for hydroxychloroquine
irreversible retinopathy therefore monitor with eye exam
contraindication for sulfasalizine
sulfa allergy
MOA for Leflunomide (Arava)
inhibits pyrimidine synthesis
boxed warning for Leflunomide (for RA) and its prodrug which is used for ms teriflunomide
do not use in pregnancy (must be on 2 forms of birth controland not plan to be pregnant for 2 years or do accelerated drug eliminatioN), may cause hepatotoxicity
Janus kinase inhibitor boxed warnings
serious infections, increased risk for malignancy, increased risk for thrombosis
what can you not use Janus kinase inhibitors with?
biologic DMARDS or potent immunosupressants
major mtx ddis
alchohol, aspirin/nsaids
entercept, adalimumab, infliximab are what class
anti TNF Biologic DMARDS which inhiit tumor necrosis factor alpha
Enbrel
Etanercept
a biologic
Humira
Adalimumab
Remicade
Infliximab
Cimzia
Cetroloizumab pegol
Simponi
Golimumab
Rituxan
Rituximab
Rituximab is a what
Non -TNF DMARD
boxed warning and warning for Anti-TNF DMARDS
Boxed: serious infections, malignancies, screen for latent TB and tx
Warning: can cause demyelinating disease, hep B reactivation, heart failure, hepatotoxicity, lupus-like syndrome, do not use with otherbiologic DMARDS or live vaccines
Storage of biologics
Do not shake or freeze, refrigiration required
Pneumonic for drugs that require drugs with filter requirements
That's my G - golimzumab (simponi) A- Amiodarone L - Lorazepam P - Phenytoin L - Lipids (1.2 micron) A - Amphotercin B (lipid formulations) **5 micron T - Taxanes (except docetaxel)
whose head is flat
mostly 0.22 microns
How often is etanercept (Enbrel) dosed and where
SC weekly into the amdomen, thigh, or upper arm
how often is adalimumab (humira) dosed and administered
SC every other week into the amdomen and thigh (not upper arm)
Normal Saline Only Pneumonic
A - Ampicillin D - Daptomycin, I - Infliximab (remicade), A - Ampicillin.sulbactram (betic) Can't - Caspofungin Eat - Ertapenem Pie - Phenytoin
dosing frequency for cetolizumab pegol (Cimzia )
every other week
biologics dosed every other week
certolizumab (cimzia) and adalimumab (HUMIRA)
golimumab dosing and location
AKA SIMPONI dosed monthly in the abdomen, thigh, or upper arm
what does rituximab (rituxan) deplete
CDB20 B cells
administration of rituximab (rituxan)
premedicate with a steroid, acetaminophen, and a antihistamine
which biologic can cause hypersensitivity and/or infusion reactions
Infliximab (remicade ANTI TNF) - infusion reaction and delayed hypersensitivity
Rituximab (rituxan, NON TNF) - serious and fatal infusion related rxn requiring premedication
storage of entercept (enbrel) and adalimumab (himira) atroom temp
14 days at room temp
Which race is lupas more common in
african american and asian
DILE drugs pneumonic
My - Methimazole Pretty - Propylthiouracil Malar - methyldopa Marking - minocycline Probably - procainimide Has - Hydralazine A - Anti-TNF Trans - Terbinafine Iant - Isoniozid Quality - Quinidine
Clinical Presentation of lupas
fatigue, depression, anorexia, weight loss, muscle pain, malar rash (buttefly), photosensiticity, joint pain and stiffness
manifistations that contribute to mortality in SLE
kidney disease (50% of patients), liver, neurologic
tests for lupas
antinuclear antibodies, anti SS DNA, anti DS DNA
non drug tx for SLE
photosensitivity (avoid suscreans and sun protection)
tx for SLE
hydrxychloroqunalone, cyclophosphamide, azathiprine, mycophenolate mofetil, cyclosporine
how long does tx for sle take to show benefit
6 months
benlysta
belimumab (for lupas)
belimumab (benylysta) MOA
IGG1 lambda monocolonial antibody which prevents the survival of B lymphocytes and reduces B cell mediated immunity and autoimmune response
what does MS attack and how does it present
the myelin sheath and causes the deterioration of cognitive function, muscle spasms, pain, incontinence, and difficulty walking with gait instability and visual disturbances
how is MI diagnosed
MRI
Copaxone
Glatiramir acetate
tx for ms (non interferon alpha)
glatiramer acetate (copaxone)warnings and side effects
warning: Chest pain
Side effects: injection site reactons, flushing, diaphoresis, dyspnea
What is the preferred MS treatment in pregnancy
Copaxone (glatiramer acetate)
Copaxone/Glatiramir Acetatedosing
SC daily or 3x per week
interferon beta products have what warnngs and side effects
psychiatric disorders, injection site necrosis, thyroid disfunction, increased LFTs
side effects: flu like
some interferon beta products contain what (besides PEG)
albumin
dosing frequency for pegilated interferon beta
every 14 days
Tysabri
Natalizumab
a monocolonial antibody for MS
Tysabri (natalizumab) has a boxed warning for what
Progressive multifocal leukoencephalopathy (PML) and is only availale through REMS
*see IBS
Simponimod (mayzent) oral immunomodulator for MS is contraindicated in what and has what significant adverse events and requires what monitoring
Macular edema, monitor eye exams, LFTs, CBC (same for fingolimod/Gilenyeya)
Contraindicated with CYP2C92/3 genotype
Fingolimod (gilyena) has to be monitored for what for how long
bradycardia, 6 hours
Teriflumide (aubagio) is contraindicated in what a MS drug
pregnancy
what are the sympotms of myesthenia gravis
eyes/vision, drooping eyelid (ptosis)
what can unmask or worsen myesthenia gravis and what cantreat
drugs, tx with cholinesterase inhibitorsto block the breakdown of each and thus cause cholinergic effects (SLUDGE)
sx of sjOgren’s syndrome and complications
dry eyes, dry mouth –> complications include dental caries, corneal ulderation, chronic oral infections
dry eyes treatment
OTC teardrops or may do cyclosporine tear drops (restasis)
restasis
cyclosporine
eye drop preservative that can cause irritation
Benzalkonium chloride
restasis/cyclosporine side effects
ocular burning
liftegrast (Xiidra) eye drop side effect
unusual taste
dry mouth tx OTC
OTC: sugar free gum with xylitol or lozenges and daily rinses with antimicrobial mouthwash
pilocarpine and cevimeline are what and are contraindicated in whom
muscarinic agents for dry mouth (RX) and are contraindicated in patients with uncontrolled asthma and narrow-angle glaucoma
what is psoriasis
a chronic, autoimmune disease that appears on the skin appearing as raised white patches with silvery white buildup
non drug tx for psoriasis
UVB phototherapy because it can cause activated T cells in the skin to die
Drug tx topical if facial or if other topical tx fails
calcinerurin inhibitors (tacrolimus) which are associated with skin cancer and lymphoma
coal tar products are used for what
dandruff, dermatitis, psoriasis
systemic retinoids are used in what cases for psoriasis
severe only
interleukin receptor antagonists for psoriasis are administered how and can cause what
SC, like every other monocololial antibody infection and diarrhea
at what dose would someone be considered immunosuppressed from steroid?
> 2 mg/kg/day or >20mg/day of prednisone or prednisone equivilent
when is hydroxychloroquine used as an alternative to lupas
when worried about liver disease
Raynaud’s is what and caused by what drugs
decreased blood flow to finders which makes it blue and is caused by sympathomimetic, beta blockers, and some chemo drugs (bleomycin, cisplatin)
how to treat reynaud’s
a DHP CCB (i.e. nifedipine)
