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systemic steroids and autoimmune conditions Flashcards

1
Q

steroids are used for
1
2

A 
inflammatory conditions 
adrenal insufficiency (to replace cortisol or aldosterone
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2
Q

___ mimics aldosterone

A

fludrocortisone

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3
Q

type of activity fludrocortisone has

used for

A

mineralocorticoid activity
-balanace of water and electrolytes

addisons disease

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4
Q

glucocoriticoids include steroids such as ___ and ____

have what type of properties

A

prednisone
hydrocoritsone

anti inflammatory

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5
Q

long term use of steroids require a ___ off

A

taper off

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6
Q

cushings syndrome is when the adrenal gland produces too much ____ or when exogenous steroids are taken in ___ doses

A

cortisol, high doses

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7
Q

addisons disease is the __ of cushings

A

opposite , the adrenal gland is not making enough coritsol

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8
Q

if exogenous steroids are stopped suddenly and not tapered it can cause ____

A

addisonian crisis

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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
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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
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11
Q

steroid potency

A

C H P P M T D B

25 20 5 5 4 4 0.75 0.6

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12
Q

dexamethasone brands

A

dexpak 6, 10, 13 day

decadron

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13
Q

hydrocortisone brand

A

solu-cortef

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14
Q

methylprednisolone brand

A

medrol

solu-medrol

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15
Q

prednisone brand

A

deltasone

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16
Q

prednisolone brand

A

millipred

orapred ODT

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17
Q

triamcinolone brand

A

kenalog

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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
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19
Q

take steroids

A

with food in the AM

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20
Q

warnings with steroids

A

cause ADRENAL SUPPRESSION

must taper

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21
Q

cortisone is a prodrug of __

A

cortisol

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22
Q

prednisone is a prodrug of

A

prednisolone

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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

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24
Q

how to tapre steroids

A

over 1-2 weeks

and reduce the dose by 10-20 percent every few days

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25
Q

common syptoms of autoimmune diseases

A

fatigue, weakness and pain

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26
Q

lab tests for detecting inflammation

A

ESR, CRP, RF, ANA

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27
Q

the use of strong immunosupressants can increase the risk of certain conditions including

A

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

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28
Q

treating acute inflammation with steroids

A

give high dose initially to quickly reduce inflammation then taper dose down to treat the remaining inflammation while preventing a rebound attack

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29
Q

medrol therapy pack what it contains

A

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

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30
Q

symptoms of RA

A 
joint swelling 
pain
stiffness
bone deformity
weakness

morning stiffness worse after rest

bilteral symmetrical disesase

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31
Q

lab tests for RA

A

anti citrullinated peptide antibody (ACPA)
RF
(RF can be positive due to another autoimmune disorder)

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32
Q

preferred initial treatment for RA

A

methotrexate

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33
Q

for patients with moderate or high disease activity despite MTX

A

a combo or DMARDS or TNF inhibitor biologic or non tnf biologic with or without MTX is recommended

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34
Q

never use two ___ ___ in combo

A

biologic DMARDS

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35
Q

what to use for RA flares

A

steroids

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36
Q

non biological DMARDS

A

methotrexate (trexall)
hydroxychloroquine (plaquenil)
sulfasalazine
leflunomide

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37
Q

trexall

A

methotrexate

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38
Q

plaquenil

A

hydroxychloroquine

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39
Q

inhibits dihydrofolate reductase inhibiting folate

A

methotrexate

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40
Q

inhibits pyrimidine synthisis

A

leflunomide (arava)

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41
Q

two nonbiologic dmards that you dont use in pregnancy

A

methotrexate and leflunomide

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42
Q

never dose methotrexate __ for RA

A

daily, its 7.5- 20mg weekly single dose never divided

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43
Q

methotrexate boxed warnings

A

hepatoxicity
myleosuppression
mucositiosis/stomatitis
pregnancy (teratogenic)

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44
Q

methotrexate CI

A

pregnancy, breastfeeding, alcoholism, chronic liver disease

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45
Q

methotrexate monitoring

A

CBC, LFTs, chest xray, hep b&c serologys

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46
Q

can give __ with MTX to decrease hematoligcal, GI and hepatic side effects

A

folate

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47
Q

plaquenil take with

A

food or milk

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48
Q

plaquenil can cause

A

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)
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49
Q

sulfasalazine CI

A

with sulfa or salicylate allergy

can cause yellow orange discoloration of the skin or urine

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50
Q

leflunamide avoid in

A

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.

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51
Q

with leflunomide use accelerate drug elimination upon discontinuation

A

1) cholestyramine 8 grams tid x 11 days

2) activated charcoal susp. 50 gram q12h x 11 days

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52
Q

methotrexate should not be taken with

A

alcohol

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53
Q

renal elimination of mtx is decreased by

A

nsaids and aspirin use caution can cause toxicity

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54
Q

all jax inhibitors are

A

PO and end int -tinib

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55
Q

jax inhibitors boxed warnings

A
  • serious infections including TB (screen for active and latent before starting)
  • malignancy: increase risk
  • thrombosis: increase risk (sometimes fatal) blood clots
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56
Q

do not use jax inhibitors with

A

biologic DMARDs

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57
Q

jax inhibitors listed

A

xeljanz (tofacitinib)
baricitinib (olumiant)
upadacitinib (rinvoq)

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58
Q

anti TNF biologic dmards stands for

A

tumor necrosis factor alpha inhibitors

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59
Q

anti tnf biologic dmards

A 
etanercept (enbrel)
adalimumb (humira)
infliximab (remicade)
certolizumab pegol (cimzia)
golimumab (simponi)
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60
Q

entanercept brand given

A

enbrel SC weekly

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61
Q

adalimumab brand given

A

humira sc every other week

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62
Q

infliximab brand given

A

remicade iv every 8 weeks

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63
Q

certolizumab brand given

A

cimzia sc every other week

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64
Q

golimumab brand given

A

simponi sc given monthly

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65
Q

weekly anti tnf dmard

A

enbrel (etanercept)

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66
Q

every other week tnf dmard

A

humira

cimzia

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67
Q

iv dmard

A

remicade

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68
Q

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

A

initial therapy

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69
Q

simponi (golimumab) requires a ___

A

filter

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70
Q

infliximab (remicade) ___ only

A

ns only

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71
Q

boxed warnings with anti tnf biologic dmards

A

serious infections
latent tb-treat if needed prior to treatment
malignancies

72
Q

CI for anti-tnfi biologic dmards

A

active systemic infections

73
Q

warnings anti tnf biologic dmards

A 
demyelnating disease
hep b reactivation
heart failure
hepatotoxicity
lupus like syndrome

-do not use with other biologic dmards or live vaccines

74
Q

prior to starting anti biologic dmards test for

A

tb test
HBV

routine: signs of infection: CBC, LFTs,HBV, TB (annually)

75
Q

do not __ or freeze anti tnf biologic dmards

76
Q

depletes CD20 B cells

77
Q

rituxan

78
Q

rituximab is

A

a non tnf biologic dmard, does work through TNF inhbition like the others

79
Q

rituximab is administerd how

and you must

A

IV

premedicate with steroid, tylenol and an antihistamine because of infusion related reaction

80
Q

boxed warnings for rituxan (rituximab)

A

HBV reactivation
infusion related reactions
screen high risk groups for HBV, HCV

81
Q

warnings for rituximab

A

do not give with other biologic dmards or live vaccines

82
Q

anakinra (kineret) MOA

A

il-1 receptor antagonist (non tnf inhbitors)

83
Q

anakinra

84
Q

anakinra warnings

A

malignancies and serious infections

85
Q

abatacept brand

86
Q

abatacept (orencia) MOA

A

bind cd80 and cd86, blocking cd28

87
Q

abatacept (orencia) given

88
Q

two il6 receptor antagonists

A

tocilizumab (actemra)

sarilumab (kevzara)

89
Q

il6 recptor antagonists (non tnf dmard biologics)

boxed warnings

A

serious infections

do not give with other biologic dmards or live vaccines

90
Q

rasuvo and otrexup are

A

sq auto injectors of MTX into abdomen or upper thigh only!

91
Q

etanercept and adalimumab (enbrel and humira) can be stored how long at room temp

A

14 days two weeks ,

abdomen and thigh for SC injection

92
Q

drugs that can cause DILE

A

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
Q

symptoms of DILE

A 
fatigue
depression
anorexia
weight loss
muscle pain
malar rash (butterfly rash)
photosensitivity
joint pain and sensitivity
94
Q

most common manifestations of lupus

A

arthritis and cutaneous

but renal, hematological, and neurological contribute largely to morbidity and mortality

95
Q

lupus ____ develops in over 50% of patients

A

nephritis (kidney disease)

96
Q

common lab findings with lupus

A

positive ANA
positive anti-ssDNA
positive dsDNA

97
Q

non drug treatment for lupus

A

rest
smoking cessation
photosensitivty so avoid sun and use sunscreen

98
Q

treatment of lupus

A

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
Q

drug approved in recent years for advanced disease of lupus

A

Belimumab (Benlysta)

100
Q

Benlysta

A

benlimumab for lupus!

101
Q

benlysta (benlimumab) comes in what forms

102
Q

warnings with benlysta

A

serious sometimes fatal infections
malignancy
do not give with other biologic dmards or live vaccines

103
Q

MS is a chronic progressive autoimmune disease in which the immune system attacks the___ ___ in the brain

A

mylein sheath

104
Q

early symptoms of MS

A

fatigue, numbness, blurred vision, tingling

105
Q

later symptoms of MS

A 
deterioration of cognitive function
muscle spasms
pain
incontinence
gait instability
106
Q

tests for MS

A

MRI

spinal fluid tests

107
Q

primary goal of MS treatment

A

prevention of disease progression

what is lost in neuronal function cannot be regained

108
Q

chemotherapeutic agent approved for MS

A

mitoxantrone

109
Q

agent for MS relapses

A

steroids (corticotropin) HP Acthar

110
Q

mainstay treatments for patients with relapsing forms of MS

A

interferon betas

and glatiramer acetate

111
Q

interferon betas

A 
betaseron
avonex
rebif
extavia
plegridy
112
Q

glatiramer acetate brand

A

copaxone (an immune modulator)

113
Q

how is copaxone (glatiramer) given

114
Q

pegylated interferon beta is

A

plegridy, it can be given every 14 days ( allows for more convient dosing

115
Q

glatiramer (copaxone) dosing

A

20 mg SQ daily
or
40 mg SQ 3 times weekly

116
Q

warnings with glatiramer

A

chest pain

117
Q

side effects of copaxone

A

injection site reactions
flushing
diaphoresis
dyspnea

118
Q

preferred agent for MS during pregnancy

A

copaxone (glatiramer)

119
Q

interferon beta-1a brand

A

avonex and rebif

120
Q

avonex dose

121
Q

rebif dose

A

sc 3 times weekly

122
Q

interferon beta 1b brands

A

betaseron and extavia

123
Q

interferon beta 1b dosing

A

sc every other day

124
Q

peginterferon beta 1a brand

125
Q

plegridy doseing

A

SC every 14 days

126
Q

interferon beta warnings

A

psychiatric disorders
injection site necrosis
increase lfts
thyroid dysfunction(hyper and hypo)

127
Q

interferons SE

A

flu like symptoms

128
Q

what to do with the air bubble in interferons

A

do not expel due to loss of dose

129
Q

some formulations of interferons contain what

130
Q

oral immunomodulators

A

teriflunomide (aubagio)
fingolimod (gilenya)
siponimoid (mayzent)

131
Q

teriflunomide brand

132
Q

aubagio is CI in

teriflunomide

133
Q

fingolimod brand

134
Q

fingolimod can cause

A

bradycardia! extreme
must get baseline ECG
and monitored for 6 hours after first dose

135
Q

who is gilenya (fingolimod) CI in

A

history of CVD or stroke

use caution with other drugs that slow the heart rate

136
Q

other AE of fingolimoid (gilenya)

A

macular edema (eye exam)
hepatotoxicity (LFTs)
myleosuppression (CBC)

137
Q

siponimoid brand

138
Q

mayzent (siponimoid) CI with

A

cyp2c93/3 genotype must test before giving

139
Q

mayzent AE

A

macular edema
hepatotoxicity
myleosupression

140
Q

natalizumab brand

141
Q

tysarbi (natalizumab) is given

142
Q

tysarbi MOA

A

monoclonal antibody that binds to the alpha 4 subunit of integrins expressed on the surface of leukocytes

143
Q

boxed warning with tysarbi (natalizumab

A

progressive multifocal leukoencephelopathy (PML)

only available through REMS!

144
Q

propanolol can be used for

A

tremor with MS

145
Q

if depression of concern with MS choose

A

SNRI bc it will also help with neuropathic pain

146
Q

drugs that can cause or worsen raynauds

A

beta blockers
bleomycin, cisplatin
amphetamines, sudafed, cocain, methamphetamine

147
Q

raynauds

A

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
Q

drug treatment for raynauds

A

vasodilation to improve blood flow
CCB- nifedipine
other CCBS can be used for prevention

149
Q

other drugs for raynauds to vasodilate

A

iloprost
topical nitroglycerin
pde 5 I

150
Q

celiac disease is an immune response to eating ___ a protein found in __ __ __

A

gluten

wheat, barley, rye

151
Q

most effective treatment for celiac

A

avoid gluten entirely

152
Q

common symptoms of celiac disease

A

diarrhea
abdominal pain
bloating
weight loss

153
Q

the active drug is gluten free but the excipents may contain

154
Q

what keyword to look for on package insert excepients for gluten allergy

A

starch which will either be

corn, potato, tapioca, or wheat

155
Q

myasthenia gravis causes a weakness in

A

skeletal muscles

eyes, face, neck, limbs

156
Q

symptoms of MG include

A

changes to vision (double vision, drooping eyelid)
problems with chewing/swallowing
weakness in the neck/ jaw

157
Q

drugs that can worsen or unmask MG

A 
aminoglycosides 
quinolones
magnesium salts 
antiarrythmics
beta blockers
calcium channel blockers
antipsychotics
muscle relaxers
local anesthetics
158
Q

mainstay of tx MG

A

pyridostigmine (mestinon)

159
Q

pyridostigmine warnings

A

increase of cholinergic effects

SLUD

160
Q

sjogren syndrome

A

an autoimmune disease with dry eyes and dry mouth

161
Q

treatment of dry eyes

A

otc eye drops artificial tears are first line
systane, refresh, clear eyes, liquifilm

cyclosporine (restasis), lifitegrast (xiidra) - if other things fail

162
Q

restasis generic

A

cyclosporine

163
Q

how long does restasis take to work

A

3-6 months

164
Q

lifitegrast brand

A

xiidra ( can cause unusual taste )

165
Q

dry mouth treatment

A

non drug tx:
sugar free chewing gum
lozenges
rinses with antimicrobial mouthwashes

Rx:
muscarinic antagonists (pilocarpine, cevimeline)
166
Q

psoriasis is an autoimmune disease that shows up on the

167
Q

what does plaque psorasis look like

A

raised red patches covered with silvery white buildup

168
Q

non drug tx of psoriasis

A

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
Q

steroids in psorasis

A

use high potency steroids only short term due to risk of side effects
can be used as monotherapy or with other agents

170
Q

tazarotene brand

171
Q

tazorac is a

A

topical retinoid

172
Q

tazarotene plus halobetasol

173
Q

coal tar products

A

are messy time consuming and stain clothing

also used for dandruff and dermatitis

174
Q

anthralin is

A

a keratolytic containing salicylic acid

175
Q

calciopotriene is a

A

vit d analog

176
Q

calcioptriene + betamethasone brand

NAPLEX (24 decks)

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