Systemic steroids and autoimmune conditions pt 1 Flashcards
What are the two primary endogenous steroids and where are they typically produced?
Cortisol, replaced by any of the steroids
Aldosterone, which is replaced by giving fludrocortisone
Excreted by the adrenal gland
Difference between aldosterone and cortisol
Aldosterone = mineralocorticoid Cortisol = glucocorticoid
What is the role of mineralocorticoids?
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)
What is the role of glucocorticoids?
Anti-inflammatory effects
What is Cushing’s syndrome?
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
What is it called when the adrenal gland stops producing cortisol due to excess systemic steroids?
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
What is Addison’s disease?
Adrenal gland isn’t producing enough cortisol
Addisonian crisis can be fatal, can be caused by stopping exogenous steroids suddenly
Steroids from least potent to most potent with dose equivalence
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
Dexamethasone brand
DexPak 6, 10, or 13 day
Methylprednisolone brand
Medrol, Medrol therapy pack, solumedrol, a-methapred, depo-medrol
Prednisone brand
Deltasone
Prednisone Intensol
Prednisolone brand
Millipred
Orapred ODT
Pediapred
Triamcinolone brand
Kenalog
When should steroids be taken? (time of day)
Between 7-8 am to mimic the “natrual diurnal cortisol release”
Short-term side effects of steroids:
Increased BG
Increased BP
Increased intraocular pressure (glaucoma)
Emotional insability, euphoria, mood swings
When do you taper steroids and why is it important?
Taper slowly if taken for longer than 14 days
HPA axis suppression may lead to adrenal crisis and death if stopped immediately
Long-term side effects of steroids
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)
True or false: prednisolone is a prodrug of prednisone
False
Prednisone is a prodrug of prednisolone
True or false: Cortisone is a prodrug of cortisol
True
When is a patient considered immunosuppressed? (dose/duration)
When taking >/= 2 mg/kg/day or > 20mg/day of prednisone or prednisone equivalent for >/= 2 weeks
Common symptoms of most autoimmune conditions include…
fatigue, weakness, pain
Testing required before starting strong immunosuppressants
Tb and hep B/C because these can be reactivated with the use of strong immunosuppressants
When should live vaccines be given to patients being started on immunosuppressants?
Before they start the immunosuppressant
How to rule out RA vs OA
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
What are DMARDs
Disease modifying antirheumatic drugs
Slow disease process and help prevent further joint damage
Preferred initial therapy for RA
methotrexate
Can you use two biologic DMARDs together?
No - risk of serious fatal infections
List the non-biologic DMARDs
Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide (Arava), tofacitinib (Xeljanz)
SC methotrexate options
Otrexup
Rasuvo
SubQ autoinjectors
Trexall
Methotrexate oral tablet
Xatmep
Oral solution methotrexate for pediatric patients
Methotrexate dosing for RA, boxed warnings, side effects
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
Folate supplementation for methotrexate
5 mg PO weekly on the day following MTX
Hydroxychloroquine brand, dose, warnings, side effects, monitoring
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
Sulfasalazine dosing, contraindications, warnings, side effects
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
Leflunomide brand, dose, boxed warnings, contraindications
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)
Accelerated drug elimination for leflunomide
Arava
Give cholestyramine 8 g PO TID x 11 days
or activated charcoal suspension 50 g PO q 12h x 11 days
Tofacitinib brand, dosing, warnings
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
Etanercept brand, dose
Enbrel
50 mg subQ weekly
Adalimumab brand, dose
40 mg SC every other week
Can do 40 mg weekly if not taking MTX
Infliximab brand, dose, notes
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
Certolizumab pegol brand, dose
Cimzia
400 mg subQ at weeks 0, 2, and 4 and then 200 mg every other week
Golimumab brand, dose
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)
Storage etanercept
Enbrel
Room tempt for 14 days or refrigerated
Storage adalimumab
Humira
Room tempt for 14 days or refrigerated
Counseling for biologic injections (anti-TNF)
Do not shake
Check for particles or discoloration
Store in fridge, let warm to room temp before injecting
Counseling for etanercept reconstitution
Enbrel
Foaming is normal, but final solution should be clear and colorless with no particles
Golilumab, etanercept injection sites
Inject SC in the abdomen, thigh, or upper arm
Can pregnant women use biologics?
Safety data is limited
Patients should register with a Pregnancy Exposure Registry to record pregnancy outcomes
True or false: Needles have to be purchased separately for biologics injections
False, theyre supplied with the kits
Rituximab brand, dose, MOA, boxed warnings, warnings
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
Sarilumab brand, dose, notes
Kevzara
200 mg subQ every 2 weeks
Do not start if liver enzymes are elevated, ANC is low, or platelets are low
