systemic steroids and autoimmune conditions Flashcards
1
Q
steroids are used for
1
2
A
inflammatory conditions adrenal insufficiency (to replace cortisol or aldosterone
2
Q
___ mimics aldosterone
A
fludrocortisone
3
Q
type of activity fludrocortisone has
used for
A
mineralocorticoid activity
-balanace of water and electrolytes
addisons disease
4
Q
glucocoriticoids include steroids such as ___ and ____
have what type of properties
A
prednisone
hydrocoritsone
anti inflammatory
5
Q
long term use of steroids require a ___ off
A
taper off
6
Q
cushings syndrome is when the adrenal gland produces too much ____ or when exogenous steroids are taken in ___ doses
A
cortisol, high doses
7
Q
addisons disease is the __ of cushings
A
opposite , the adrenal gland is not making enough coritsol
8
Q
if exogenous steroids are stopped suddenly and not tapered it can cause ____
A
addisonian crisis
9
Q
long term effects of steroids (cushings sydrome)
A
acne gi bleeding/ulcers diabetes hirstuism irregular or absent periods poor bone health infection impaired wound healing growth problems muscle wasting pink purple stretch marks bruising easily moon face (fat deposits in face) buffalo hump (fat deposit on back) glaucoma cataracts psychiatric changes anxiety depression delrium psychosis headache intracranial hypertension hypothyroidism
10
Q
ways to reduce systemic steroid risks
A
- use alternate day dosing
- local joint injections
- low systemic absorption (like entocort ec) budesonide
- inhaled steroids (lungs)
- lowest possible dose for shortest possible time
11
Q
steroid potency
A
C H P P M T D B
25 20 5 5 4 4 0.75 0.6
12
Q
dexamethasone brands
A
dexpak 6, 10, 13 day
decadron
13
Q
hydrocortisone brand
A
solu-cortef
14
Q
methylprednisolone brand
A
medrol
solu-medrol
15
Q
prednisone brand
A
deltasone
16
Q
prednisolone brand
A
millipred
orapred ODT
17
Q
triamcinolone brand
A
kenalog
18
Q
short term SE of steroids
A
increase blood glucose (diabetes)
increase blood pressure (hypertension)
increase intraocular pressure (glaucoma)
emotional instablility (psychiatric conditions)
- increase appetite and weight gain
- insomnia
19
Q
take steroids
A
with food in the AM
20
Q
warnings with steroids
A
cause ADRENAL SUPPRESSION
must taper
21
Q
cortisone is a prodrug of __
A
cortisol
22
Q
prednisone is a prodrug of
A
prednisolone
23
Q
a patient is immunocompromised on steroids when
A
using 2 mg/kg/day or greater
or
20mg/day of prednisone or prednisone equivalent
for greater than 2 weeks
24
Q
how to tapre steroids
A
over 1-2 weeks
and reduce the dose by 10-20 percent every few days
25
common syptoms of autoimmune diseases
fatigue, weakness and pain
26
lab tests for detecting inflammation
ESR, CRP, RF, ANA
27
the use of strong immunosupressants can increase the risk of certain conditions including
reactivation of tb. hep b and hep c
-testing and treatment must be done prior to the start of immunosupressant drugs
viruses
-if the virus can be prevented by a live vaccine it must be given prior to the start of immunosupressant therapy
lymphomas and certain skin cancers
infections
28
treating acute inflammation with steroids
give high dose initially to quickly reduce inflammation then taper dose down to treat the remaining inflammation while preventing a rebound attack
29
medrol therapy pack what it contains
21 x 4mg tablets used in a tapered schedule over 6 days
day 1: 6 tabs
2: 5 tabs
3: 4 tabs
4: 3 tabs
5: 2 tabs
6: 1 tab
30
symptoms of RA
```
joint swelling
pain
stiffness
bone deformity
weakness
```
morning stiffness worse after rest
bilteral symmetrical disesase
31
lab tests for RA
anti citrullinated peptide antibody (ACPA)
RF
(RF can be positive due to another autoimmune disorder)
32
preferred initial treatment for RA
methotrexate
33
for patients with moderate or high disease activity despite MTX
a combo or DMARDS or TNF inhibitor biologic or non tnf biologic with or without MTX is recommended
34
never use two ___ ___ in combo
biologic DMARDS
35
what to use for RA flares
steroids
36
non biological DMARDS
methotrexate (trexall)
hydroxychloroquine (plaquenil)
sulfasalazine
leflunomide
37
trexall
methotrexate
38
plaquenil
hydroxychloroquine
39
inhibits dihydrofolate reductase inhibiting folate
methotrexate
40
inhibits pyrimidine synthisis
leflunomide (arava)
41
two nonbiologic dmards that you dont use in pregnancy
methotrexate and leflunomide
42
never dose methotrexate __ for RA
daily, its 7.5- 20mg weekly single dose never divided
43
methotrexate boxed warnings
hepatoxicity
myleosuppression
mucositiosis/stomatitis
pregnancy (teratogenic)
44
methotrexate CI
pregnancy, breastfeeding, alcoholism, chronic liver disease
45
methotrexate monitoring
CBC, LFTs, chest xray, hep b&c serologys
46
can give __ with MTX to decrease hematoligcal, GI and hepatic side effects
folate
47
plaquenil take with
food or milk
48
plaquenil can cause
irreversible retinopathy (EYE EXAM)
```
n/v/d
abdominal pain
rash
itching
HA
vision changes
pigmentation changes or skin and hair
bone marrow supression(anemia, leukopenia, thrombocytopenia)
```
49
sulfasalazine CI
with sulfa or salicylate allergy
| can cause yellow orange discoloration of the skin or urine
50
leflunamide avoid in
pregnancy
hepatotoxicity
must have neg. preg. test prior to starting and use 2 forms of BC during treatment. if preg. is desired must wait 2 years after accelerated elimination procedure.
51
with leflunomide use accelerate drug elimination upon discontinuation
1) cholestyramine 8 grams tid x 11 days
| 2) activated charcoal susp. 50 gram q12h x 11 days
52
methotrexate should not be taken with
alcohol
53
renal elimination of mtx is decreased by
nsaids and aspirin use caution can cause toxicity
54
all jax inhibitors are
PO and end int -tinib
55
jax inhibitors boxed warnings
- serious infections including TB (screen for active and latent before starting)
- malignancy: increase risk
- thrombosis: increase risk (sometimes fatal) blood clots
56
do not use jax inhibitors with
biologic DMARDs
57
jax inhibitors listed
xeljanz (tofacitinib)
baricitinib (olumiant)
upadacitinib (rinvoq)
58
anti TNF biologic dmards stands for
tumor necrosis factor alpha inhibitors
59
anti tnf biologic dmards
```
etanercept (enbrel)
adalimumb (humira)
infliximab (remicade)
certolizumab pegol (cimzia)
golimumab (simponi)
```
60
entanercept brand given
enbrel SC weekly
61
adalimumab brand given
humira sc every other week
62
infliximab brand given
remicade iv every 8 weeks
63
certolizumab brand given
cimzia sc every other week
64
golimumab brand given
simponi sc given monthly
65
weekly anti tnf dmard
enbrel (etanercept)
66
every other week tnf dmard
humira
| cimzia
67
iv dmard
remicade
68
mtx is first line and anti tnf biologics are add on therapy however if the initial presentation is severe they can be started as ___ ___ with or without MTX
initial therapy
69
simponi (golimumab) requires a ___
filter
70
infliximab (remicade) ___ only
ns only
71
boxed warnings with anti tnf biologic dmards
serious infections
latent tb-treat if needed prior to treatment
malignancies
72
CI for anti-tnfi biologic dmards
active systemic infections
73
warnings anti tnf biologic dmards
```
demyelnating disease
hep b reactivation
heart failure
hepatotoxicity
lupus like syndrome
```
-do not use with other biologic dmards or live vaccines
74
prior to starting anti biologic dmards test for
tb test
HBV
routine: signs of infection: CBC, LFTs,HBV, TB (annually)
75
do not __ or freeze anti tnf biologic dmards
shake
76
depletes CD20 B cells
rituximab
77
rituxan
rituximab
78
rituximab is
a non tnf biologic dmard, does work through TNF inhbition like the others
79
rituximab is administerd how
| and you must
IV
| premedicate with steroid, tylenol and an antihistamine because of infusion related reaction
80
boxed warnings for rituxan (rituximab)
HBV reactivation
infusion related reactions
screen high risk groups for HBV, HCV
81
warnings for rituximab
do not give with other biologic dmards or live vaccines
82
anakinra (kineret) MOA
il-1 receptor antagonist (non tnf inhbitors)
83
anakinra
sc daily
84
anakinra warnings
malignancies and serious infections
85
abatacept brand
orencia
86
abatacept (orencia) MOA
bind cd80 and cd86, blocking cd28
87
abatacept (orencia) given
IV and SQ
88
two il6 receptor antagonists
tocilizumab (actemra)
| sarilumab (kevzara)
89
il6 recptor antagonists (non tnf dmard biologics)
| boxed warnings
serious infections
| do not give with other biologic dmards or live vaccines
90
rasuvo and otrexup are
sq auto injectors of MTX into abdomen or upper thigh only!
91
etanercept and adalimumab (enbrel and humira) can be stored how long at room temp
14 days two weeks ,
abdomen and thigh for SC injection
92
drugs that can cause DILE
my pretty malar marking probably has a transIent quality
```
M-methimazole
P- PTU
M- methyldopa
M-minocycline
p- procanimide
h- hydralazine (bidil)
a- anti-tnf agents
t- terbinafine
I- isoniazide
q- quinidine
```
93
symptoms of DILE
```
fatigue
depression
anorexia
weight loss
muscle pain
malar rash (butterfly rash)
photosensitivity
joint pain and sensitivity
```
94
most common manifestations of lupus
arthritis and cutaneous
| but renal, hematological, and neurological contribute largely to morbidity and mortality
95
lupus ____ develops in over 50% of patients
nephritis (kidney disease)
96
common lab findings with lupus
positive ANA
positive anti-ssDNA
positive dsDNA
97
non drug treatment for lupus
rest
smoking cessation
photosensitivty so avoid sun and use sunscreen
98
treatment of lupus
combo of drugs to minimize use of steroids
mild disease may do well on nsaids but use with a PPI
-many patient will require one or more immunosuppressants/cytotoxic agents
(hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate, cyclosporine)
can take up to 6 months to see results
-with the exception of plaquenil, these drugs are not fda approved for SLE
drug that is fda approved: belimumab for advanced disease
99
drug approved in recent years for advanced disease of lupus
Belimumab (Benlysta)
100
Benlysta
benlimumab for lupus!
101
benlysta (benlimumab) comes in what forms
SQ and IV
102
warnings with benlysta
serious sometimes fatal infections
malignancy
do not give with other biologic dmards or live vaccines
103
MS is a chronic progressive autoimmune disease in which the immune system attacks the___ ___ in the brain
mylein sheath
104
early symptoms of MS
fatigue, numbness, blurred vision, tingling
105
later symptoms of MS
```
deterioration of cognitive function
muscle spasms
pain
incontinence
gait instability
```
106
tests for MS
MRI
| spinal fluid tests
107
primary goal of MS treatment
prevention of disease progression
| what is lost in neuronal function cannot be regained
108
chemotherapeutic agent approved for MS
mitoxantrone
109
agent for MS relapses
steroids (corticotropin) HP Acthar
110
mainstay treatments for patients with relapsing forms of MS
interferon betas
| and glatiramer acetate
111
interferon betas
```
betaseron
avonex
rebif
extavia
plegridy
```
112
glatiramer acetate brand
copaxone (an immune modulator)
113
how is copaxone (glatiramer) given
SC
114
pegylated interferon beta is
plegridy, it can be given every 14 days ( allows for more convient dosing
115
glatiramer (copaxone) dosing
20 mg SQ daily
or
40 mg SQ 3 times weekly
116
warnings with glatiramer
chest pain
117
side effects of copaxone
injection site reactions
flushing
diaphoresis
dyspnea
118
preferred agent for MS during pregnancy
copaxone (glatiramer)
119
interferon beta-1a brand
avonex and rebif
120
avonex dose
IM weekly
121
rebif dose
sc 3 times weekly
122
interferon beta 1b brands
betaseron and extavia
123
interferon beta 1b dosing
sc every other day
124
peginterferon beta 1a brand
plegridy
125
plegridy doseing
SC every 14 days
126
interferon beta warnings
psychiatric disorders
injection site necrosis
increase lfts
thyroid dysfunction(hyper and hypo)
127
interferons SE
flu like symptoms
128
what to do with the air bubble in interferons
do not expel due to loss of dose
129
some formulations of interferons contain what
albumin
130
oral immunomodulators
teriflunomide (aubagio)
fingolimod (gilenya)
siponimoid (mayzent)
131
teriflunomide brand
aubagio
132
aubagio is CI in
| teriflunomide
pregnancy
133
fingolimod brand
gilenya
134
fingolimod can cause
bradycardia! extreme
must get baseline ECG
and monitored for 6 hours after first dose
135
who is gilenya (fingolimod) CI in
history of CVD or stroke
| use caution with other drugs that slow the heart rate
136
other AE of fingolimoid (gilenya)
macular edema (eye exam)
hepatotoxicity (LFTs)
myleosuppression (CBC)
137
siponimoid brand
mayzent
138
mayzent (siponimoid) CI with
cyp2c9*3/*3 genotype must test before giving
139
mayzent AE
macular edema
hepatotoxicity
myleosupression
140
natalizumab brand
tysarbi
141
tysarbi (natalizumab) is given
IV
142
tysarbi MOA
monoclonal antibody that binds to the alpha 4 subunit of integrins expressed on the surface of leukocytes
143
boxed warning with tysarbi (natalizumab
progressive multifocal leukoencephelopathy (PML)
| only available through REMS!
144
propanolol can be used for
tremor with MS
145
if depression of concern with MS choose
SNRI bc it will also help with neuropathic pain
146
drugs that can cause or worsen raynauds
beta blockers
bleomycin, cisplatin
amphetamines, sudafed, cocain, methamphetamine
147
raynauds
exposure to cold and or stress leading to vasospasm in the extremeties
most commonly fingers and toes
skin turns white then purple it is painful
148
drug treatment for raynauds
vasodilation to improve blood flow
CCB- nifedipine
other CCBS can be used for prevention
149
other drugs for raynauds to vasodilate
iloprost
topical nitroglycerin
pde 5 I
150
celiac disease is an immune response to eating ___ a protein found in __ __ __
gluten
| wheat, barley, rye
151
most effective treatment for celiac
avoid gluten entirely
152
common symptoms of celiac disease
diarrhea
abdominal pain
bloating
weight loss
153
the active drug is gluten free but the excipents may contain
gluten
154
what keyword to look for on package insert excepients for gluten allergy
starch which will either be
| corn, potato, tapioca, or wheat
155
myasthenia gravis causes a weakness in
skeletal muscles
| eyes, face, neck, limbs
156
symptoms of MG include
changes to vision (double vision, drooping eyelid)
problems with chewing/swallowing
weakness in the neck/ jaw
157
drugs that can worsen or unmask MG
```
aminoglycosides
quinolones
magnesium salts
antiarrythmics
beta blockers
calcium channel blockers
antipsychotics
muscle relaxers
local anesthetics
```
158
mainstay of tx MG
pyridostigmine (mestinon)
159
pyridostigmine warnings
increase of cholinergic effects
| SLUD
160
sjogren syndrome
an autoimmune disease with dry eyes and dry mouth
161
treatment of dry eyes
otc eye drops artificial tears are first line
systane, refresh, clear eyes, liquifilm
cyclosporine (restasis), lifitegrast (xiidra) - if other things fail
162
restasis generic
cyclosporine
163
how long does restasis take to work
3-6 months
164
lifitegrast brand
xiidra ( can cause unusual taste )
165
dry mouth treatment
non drug tx:
sugar free chewing gum
lozenges
rinses with antimicrobial mouthwashes
```
Rx:
muscarinic antagonists (pilocarpine, cevimeline)
```
166
psoriasis is an autoimmune disease that shows up on the
skin
167
what does plaque psorasis look like
raised red patches covered with silvery white buildup
168
non drug tx of psoriasis
UV light causes activated t cells in the skin to die
brief daily exposures to sunlight can help psoriasis but intense exposure worsens it
UVB phototherapy (artificial) improves mild to moderate
169
steroids in psorasis
use high potency steroids only short term due to risk of side effects
can be used as monotherapy or with other agents
170
tazarotene brand
tazorac
171
tazorac is a
topical retinoid
172
tazarotene plus halobetasol
duobrii
173
coal tar products
are messy time consuming and stain clothing
| also used for dandruff and dermatitis
174
anthralin is
a keratolytic containing salicylic acid
175
calciopotriene is a
vit d analog
176
calcioptriene + betamethasone brand
talconex
