Systemic steroids and autoimmune conditions pt 1

Question 1

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

Answer 1

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

Question 2

Difference between aldosterone and cortisol

Answer 2

Aldosterone = mineralocorticoid
Cortisol = glucocorticoid

Question 3

What is the role of mineralocorticoids?

Answer 3

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)

Question 4

What is the role of glucocorticoids?

Answer 4

Anti-inflammatory effects

Question 5

What is Cushing’s syndrome?

Answer 5

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

Question 6

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

Answer 6

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

Question 7

What is Addison’s disease?

Answer 7

Adrenal gland isn’t producing enough cortisol

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

Question 8

Steroids from least potent to most potent with dose equivalence

Answer 8

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

Question 9

Dexamethasone brand

Answer 9

DexPak 6, 10, or 13 day

Question 10

Methylprednisolone brand

Answer 10

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

Question 11

Prednisone brand

Answer 11

Deltasone

Prednisone Intensol

Question 12

Prednisolone brand

Answer 12

Millipred
Orapred ODT
Pediapred

Question 13

Triamcinolone brand

Answer 13

Kenalog

Question 14

When should steroids be taken? (time of day)

Answer 14

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

Question 15

Short-term side effects of steroids:

Answer 15

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

Question 16

When do you taper steroids and why is it important?

Answer 16

Taper slowly if taken for longer than 14 days

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

Question 17

Long-term side effects of steroids

Answer 17

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)

Question 18

True or false: prednisolone is a prodrug of prednisone

Answer 18

False

Prednisone is a prodrug of prednisolone

Question 19

True or false: Cortisone is a prodrug of cortisol

Answer 19

True

Question 20

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

Answer 20

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

Question 21

Common symptoms of most autoimmune conditions include…

Answer 21

fatigue, weakness, pain

Question 22

Testing required before starting strong immunosuppressants

Answer 22

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

Question 23

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

Answer 23

Before they start the immunosuppressant

Question 24

How to rule out RA vs OA

Answer 24

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

Question 25

What are DMARDs

Answer 25

Disease modifying antirheumatic drugs | Slow disease process and help prevent further joint damage

Question 26

Preferred initial therapy for RA

Answer 26

methotrexate

Question 27

Can you use two biologic DMARDs together?

Answer 27

No - risk of serious fatal infections

Question 28

List the non-biologic DMARDs

Answer 28

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

Question 29

SC methotrexate options

Answer 29

Otrexup Rasuvo SubQ autoinjectors

Question 30

Trexall

Answer 30

Methotrexate oral tablet

Question 31

Xatmep

Answer 31

Oral solution methotrexate for pediatric patients

Question 32

Methotrexate dosing for RA, boxed warnings, side effects

Answer 32

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

Question 33

Folate supplementation for methotrexate

Answer 33

5 mg PO weekly on the day following MTX

Question 34

Hydroxychloroquine brand, dose, warnings, side effects, monitoring

Answer 34

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

Question 35

Sulfasalazine dosing, contraindications, warnings, side effects

Answer 35

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

Question 36

Leflunomide brand, dose, boxed warnings, contraindications

Answer 36

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)

Question 37

Accelerated drug elimination for leflunomide

Answer 37

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

Question 38

Tofacitinib brand, dosing, warnings

Answer 38

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

Question 39

Etanercept brand, dose

Answer 39

Enbrel | 50 mg subQ weekly

Question 40

Adalimumab brand, dose

Answer 40

40 mg SC every other week | Can do 40 mg weekly if not taking MTX

Question 41

Infliximab brand, dose, notes

Answer 41

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

Question 42

Certolizumab pegol brand, dose

Answer 42

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

Question 43

Golimumab brand, dose

Answer 43

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)

Question 44

Storage etanercept

Answer 44

Enbrel | Room tempt for 14 days or refrigerated

Question 45

Storage adalimumab

Answer 45

Humira | Room tempt for 14 days or refrigerated

Question 46

Counseling for biologic injections (anti-TNF)

Answer 46

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

Question 47

Counseling for etanercept reconstitution

Answer 47

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

Question 48

Golilumab, etanercept injection sites

Answer 48

Inject SC in the abdomen, thigh, or upper arm

Question 49

Can pregnant women use biologics?

Answer 49

Safety data is limited | Patients should register with a Pregnancy Exposure Registry to record pregnancy outcomes

Question 50

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

Answer 50

False, theyre supplied with the kits

Question 51

Rituximab brand, dose, MOA, boxed warnings, warnings

Answer 51

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

Question 52

Sarilumab brand, dose, notes

Answer 52

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