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NAPLEX - OUR cards > Systemic steroids and autoimmune conditions pt 1 > Flashcards

Systemic steroids and autoimmune conditions pt 1 Flashcards

1
Q

What are the two primary endogenous steroids and where are they typically produced?

A

Cortisol, replaced by any of the steroids
Aldosterone, which is replaced by giving fludrocortisone
Excreted by the adrenal gland

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2
Q

Difference between aldosterone and cortisol

A 
Aldosterone = mineralocorticoid
Cortisol = glucocorticoid
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3
Q

What is the role of mineralocorticoids?

A

Maintain balance of water and electrolytes
Keep blood pressure stable
So fludricortisone has an off label indication for orthostatic hypotension (mostly used for Addison’s disease)

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4
Q

What is the role of glucocorticoids?

A

Anti-inflammatory effects

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5
Q

What is Cushing’s syndrome?

A

Adrenal gland produces too much cortisol or when exogenous steroids are taken in too high of dose

Causes fat deposits (moon face), stretch marks, growth retardation, impaired wound healin, psychiatric changes, acne, diabetes, poor bone health, hirsutism (women), and irregular or absent menstrual periods

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6
Q

What is it called when the adrenal gland stops producing cortisol due to excess systemic steroids?

A

Suppression of the hypothalamic-pituitary-adrenal (HPA) axis

This is why steroids need to be tapered off, as feedback inhibition results in less of the adrenal gland production of endogenous steroids

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7
Q

What is Addison’s disease?

A

Adrenal gland isn’t producing enough cortisol

Addisonian crisis can be fatal, can be caused by stopping exogenous steroids suddenly

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8
Q

Steroids from least potent to most potent with dose equivalence

A 
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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9
Q

Dexamethasone brand

A

DexPak 6, 10, or 13 day

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10
Q

Methylprednisolone brand

A

Medrol, Medrol therapy pack, solumedrol, a-methapred, depo-medrol

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11
Q

Prednisone brand

A

Deltasone

Prednisone Intensol

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12
Q

Prednisolone brand

A

Millipred
Orapred ODT
Pediapred

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13
Q

Triamcinolone brand

A

Kenalog

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14
Q

When should steroids be taken? (time of day)

A

Between 7-8 am to mimic the “natrual diurnal cortisol release”

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15
Q

Short-term side effects of steroids:

A

Increased BG
Increased BP
Increased intraocular pressure (glaucoma)
Emotional insability, euphoria, mood swings

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16
Q

When do you taper steroids and why is it important?

A

Taper slowly if taken for longer than 14 days

HPA axis suppression may lead to adrenal crisis and death if stopped immediately

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17
Q

Long-term side effects of steroids

A

Cushing’s syndrome (Causes fat deposits (moon face), stretch marks, growth retardation, impaired wound healin, psychiatric changes, acne, diabetes, poor bone health, hirsutism (women), and irregular or absent menstrual periods)

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18
Q

True or false: prednisolone is a prodrug of prednisone

A

False

Prednisone is a prodrug of prednisolone

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19
Q

True or false: Cortisone is a prodrug of cortisol

A

True

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20
Q

When is a patient considered immunosuppressed? (dose/duration)

A

When taking >/= 2 mg/kg/day or > 20mg/day of prednisone or prednisone equivalent for >/= 2 weeks

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21
Q

Common symptoms of most autoimmune conditions include…

A

fatigue, weakness, pain

22
Q

Testing required before starting strong immunosuppressants

A

Tb and hep B/C because these can be reactivated with the use of strong immunosuppressants

23
Q

When should live vaccines be given to patients being started on immunosuppressants?

A

Before they start the immunosuppressant

24
Q

How to rule out RA vs OA

A

RA is usually symmetrical/bilateral
OA can be unilateral

Also RA stiffness and pain occurs mostly after rest, doesn’t resolve within ~30 mins-1 hr
OA stiffness from rest resolves quickly with movement

RA tests positive for anti-citrulinated peptide antibody (ACPA) and rheumatoid factor (RA) *note RF is nonspecific, just indicates inflammation

25
Q

What are DMARDs

A

Disease modifying antirheumatic drugs

Slow disease process and help prevent further joint damage

26
Q

Preferred initial therapy for RA

A

methotrexate

27
Q

Can you use two biologic DMARDs together?

A

No - risk of serious fatal infections

28
Q

List the non-biologic DMARDs

A

Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide (Arava), tofacitinib (Xeljanz)

29
Q

SC methotrexate options

A

Otrexup
Rasuvo
SubQ autoinjectors

30
Q

Trexall

A

Methotrexate oral tablet

31
Q

Xatmep

A

Oral solution methotrexate for pediatric patients

32
Q

Methotrexate dosing for RA, boxed warnings, side effects

A

7.5-20 mg once WEEKLY
Do not dose daily for RA due to risk of error and numerous incidences of adverse effects

Boxed warnings: Hepatotoxicity, myelosuppression, mucositis/stomatitis, pregnancy

Side effects: N/V/D, increased LFTs, stomatitis, alopecia, photosensitivity

33
Q

Folate supplementation for methotrexate

A

5 mg PO weekly on the day following MTX

34
Q

Hydroxychloroquine brand, dose, warnings, side effects, monitoring

A

Plaquenil
400 mg/day initially then 300 mg/day for maintenance dose
Warnings: irreversible retinopathy, loss of visual acuity, G6PD deficiency, neuromuscular weakness
Side effects: N/V/D, abdominal pain, rash, pruritus, HA, vision changes (dose-related), pigmentation changes in the skin and hair (rare)
Monitoring: eye exam and muscle strength at baseline and every 3 months after

35
Q

Sulfasalazine dosing, contraindications, warnings, side effects

A

500-1000 mg/day initially then 1000 mg BID
Contraindications: sulfa or salicylate allergy
Warnings: G6PD deficiency
Side effects: HA, rash, crystalluria (also yellow-orange coloration of the skin/urine)
Can impair folate absorption, may give 1 mg/day of folate supplementation

Take w food and 8 oz of water to prevent crystalluria

36
Q

Leflunomide brand, dose, boxed warnings, contraindications

A

Arava
100 mg PO x 3 days then 20 mg daily
Boxed warnings: embryo-fetal toxicity, hepatotoxicity
Contraindicated in pregnancy (MUST HAVE a negative pregnancy test and 2 forms of birth control, and must wait 2 years after pregnancy or use accelerated drug elimination before getting pregnant)

37
Q

Accelerated drug elimination for leflunomide

A

Arava
Give cholestyramine 8 g PO TID x 11 days
or activated charcoal suspension 50 g PO q 12h x 11 days

38
Q

Tofacitinib brand, dosing, warnings

A

Xeljanz
5 mg PO bid
XR 11 mg PO daily
Drug interactions w Cyp3A4/2C19, decrease dose to 5 mg daily in strong CYP3A4 inhibitors and strong 2C19 inhibitors
Cannot use if lymphocytes, Hgb, or ANC are low

Avoid live vaccines

39
Q

Etanercept brand, dose

A

Enbrel

50 mg subQ weekly

40
Q

Adalimumab brand, dose

A

40 mg SC every other week

Can do 40 mg weekly if not taking MTX

41
Q

Infliximab brand, dose, notes

A

Remicade
3 mg/kg IV at weeks 0, 2, 6, then every 8 weeks
Requires a filter and is stable in NS only
Can have infusion reactions (pre-treat w antihistamine etc)
Can have delayed hypersensitivity reaction, 3-12 days after administration

42
Q

Certolizumab pegol brand, dose

A

Cimzia

400 mg subQ at weeks 0, 2, and 4 and then 200 mg every other week

43
Q

Golimumab brand, dose

A

Somponi
SubQ 50 mg monthly
IV (Simponi Aria): 2 mg/kg IV infused over 30 mins at weeks 0 and 4 then every 8 weeks (requires a filter)

44
Q

Storage etanercept

A

Enbrel

Room tempt for 14 days or refrigerated

45
Q

Storage adalimumab

A

Humira

Room tempt for 14 days or refrigerated

46
Q

Counseling for biologic injections (anti-TNF)

A

Do not shake
Check for particles or discoloration
Store in fridge, let warm to room temp before injecting

47
Q

Counseling for etanercept reconstitution

A

Enbrel

Foaming is normal, but final solution should be clear and colorless with no particles

48
Q

Golilumab, etanercept injection sites

A

Inject SC in the abdomen, thigh, or upper arm

49
Q

Can pregnant women use biologics?

A

Safety data is limited

Patients should register with a Pregnancy Exposure Registry to record pregnancy outcomes

50
Q

True or false: Needles have to be purchased separately for biologics injections

A

False, theyre supplied with the kits

51
Q

Rituximab brand, dose, MOA, boxed warnings, warnings

A

Rituxan (IV)
1000 mg IV on day 1 and day 15, repeat every 16-25 weeks
MUST PREMEDICATE w steroid, APAP, antihistamine
Depletes CD20 B cells
Boxed warning: infusion related reactions, hepaptitis B reactivation, must screen high risk groups for HBV and HCV
Do not give with other DMARDs or live vaccines

52
Q

Sarilumab brand, dose, notes

A

Kevzara
200 mg subQ every 2 weeks
Do not start if liver enzymes are elevated, ANC is low, or platelets are low

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