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NAPLEX Review > Systemic Steroids and Autoimmune Conditions > Flashcards

Systemic Steroids and Autoimmune Conditions Flashcards

1
Q

Which is safer - long-term use of NSAIDs or long-term use of steroids?

A

NSAIDs

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2
Q

If there is a lack of cortisol what steroids can be given to supplement?

A

Any

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3
Q

If there is a lack of aldosterone, which steroids can be given to supplement?

A

Fludrocortisone

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4
Q

What is fludrocortisone FDA approved for? What is it used off label for?

A

FDA approved for Adidson’s disease

Off-label for orthostatic hypotension

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5
Q

Fludrocortisone mineralocorticoid or glucocorticoid activity

A

mineralocorticoid activity which is used to maintain balance of water and electrolytes

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6
Q

Which has anti-inflammatory effects, steroids with mineralocorticoid or glucocorticoid activity?

A

Glucocorticoid

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7
Q

Why do steroids need to be tapered?

A

Long-term use can cause the adrenal gland to stop producing cortisol resulting in hypothalamic-pituitary-adrenal (HPA) axis suppression
Taper off so adrenal gland can start producing cortisol again

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8
Q

Cushing’s syndrome pathophys

A

Adrenal gland produces too much cortisol

***Can also occur when steroids are taken in high doses

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9
Q

Addison’s disease pathophys

A

Adrenal gland produces not enough cortisol

***Can happen if on steroids long term and they are stopped suddenly and not tapered

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10
Q

What are long-term effects of steroids

A 
Glaucoma/cataracts
Moon face
Pink-purple stretch marks
Growth retardation, muscle wasting
Infection, impaired wound healing
Poor bone health
Diabetes
GI bleeding/esophagtis/ulcers
Acne
Psych changes
Women only: hair growth on face and irregular or absent menstrual periods
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11
Q

Which steroids are short acting? Intermediate? Long?

A

Short: Cortisone, hydrocortisone
Intermediate: prednisone, prednisolone, methylprednisolone, triamcinolone
Long: dexamethasone, betamethasone

Short acting have higher dose equivalents (25mg) while long acting have lower dose equivalents (0.6 mg)

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12
Q

Steroids least potent to most potent

A 
Cute Hot Pharmacists and Physicians Marry Together and Deliver Babies
Cortisone 
Hydrocortisone
Prednisone
Prednisolone
Methylprednisolone
Triamcinolone
Dexamethasone
Betamethasone
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13
Q

Glucocorticoids warnings, SE

A

Warnings: adrenal suppression - must taper slowly
SE: (short term) increased appetite, weight gain, emotional instability, insomnia, GI upset - take with food

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14
Q

What is cortisone the prodrug of?

A

Cortisol

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15
Q

What is prednisone the prodrug of?

A

Prednisolone

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16
Q

Dexamethasone brand name

A

DexPak 6, 10, or 13 day

Decadron

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17
Q

Hydrocortisone brand name

A

Solu-Cortef

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18
Q

Methylprednisolone brand name

A

Medrol

Solu-Medrol

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19
Q

Prednisone brand name

A

Deltasone

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20
Q

Prednisolone brand name

A

Millipred

Orapred ODT

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21
Q

Triamcinolone brand name

A

Kenalog

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22
Q

A patient is considered immunosuppressed when receiving ____ or more mg/kg/d or > ____ mg/d of prednisone or equivalent for > 2 weeks

A

2 mg/kg/d

20 mg/d

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23
Q 
What dose of each of the following is equivalent to 20mg of prednisone
Cortisone
Hydrocortisone
Prednisolone
Methylprednisolone
Triamcinolone
Dexamethasone
Betamethasone
A 
Cortisone - 100mg
Hydrocortisone - 80mg
Prednisolone - 20 mg
Methylprednisolone - 16 mg
Triamcinolone - 16 mg
Dexamethasone - 3 mg
Betamethasone - 2.4 mg
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24
Q

Use of strong immunosuppressants can increase risk of certain conditions including what?

A

Reactivation of tuberculosis and hepatitis B and C
Viruses
Lymphomas and certain skin cancers
Infections

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25
Q

Clinical presentation of rheumatoid arthritis (RA)

A

Bilateral, symmetrical symptoms
Joint swelling, pain, stiffness
Bone deformity
“Morning stiffness” or stiffness that is worse after rest

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26
Q

What lab tests can be used to diagnose RA?

A 
Anti-citrullinated peptide antibody (ACPA)
Rheumatoid factor (RF)
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27
Q

What is first-line treatment for someone with RA?

A

Disease-modifying antirheumatic drug (DMARD)

Methotrexate is DOC

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28
Q

What medications are DMARDs?

A

Methotrexate

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29
Q

What is treatment of choice in someone with RA that is not managed with MTX alone?

A

DMARD or tumor necrosis factor (TNF) or non-TNF biologic

+/- MTX

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30
Q

Why should 2 biologic DMARDs never be used together?

A

risk of serious (fatal) infections

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31
Q

Steroids commonly used in RA flares should be used at the ___ dose and for the ___ amount of time

A

Lowest dose

Shortest amount of time

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32
Q

Methotrexate (Trexall) MOA, BBW, monitoring

A

MOA: irreversibly inhibits dihydrofolate reductase, inhibiting folate
BBW: hapatotoxicity, myelosuppression, mucositis/stomatitis, pregnancy (teratogenic)
Monitor: CBC, LFTs, chest x-ray, hep B and C serologies

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33
Q

What can be given to decrease hematological, GI, and hepatic side effects of MTX?

A

Folate

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34
Q

Hydroxychloroquine (Plaquenil) warnings

A

Irreversible retinopathy

35
Q

How is MTX dosed in RA?

A

Low, once weekly dose (7.5-20mg)

36
Q

Sulfasalazine CI

A

Sulfa or salacylate allergy

37
Q

Leflunomide MOA, BBW, counseling note

A

MOA: inhibits pyrimidine synthesis
BBW: do not use in pregnancy, hepatotoxicity
Must wait 2 years after d/c to become pregnant

38
Q

What medications are janus kinase inhibitors?

A

Tofacitinib
Baricitinib
Upadacitinib (Rinvoq)

39
Q

Janus Kinase Inhibitor BBW and notes

A

BBW: serious infections, increased risk of malignancy, increased risk of thrombosis
Do NOT use with biologic DMARDs

40
Q

What medications are Anti-TNF biologic DMARDs?

A 
Entercept (Enbrel)
Adalimumab (Humira)
Infliximab (Remicade)
Certolizumab pegol (Cimzia)
Golimumab (Simponi)
41
Q

Anti-TNF biologic DMARD BBW, warnings, monitoring, counseling notes

A

BBW: Serious infections, screen for latent TB
Warnings: demyelination disease, hepatitis B reactivation, HF, hepatotoxicity, lupus-like syndrome; do NOT use with other biologic DMARDs or live vaccines
Monitoring: TB and HBV test prior to initiation; signs of infection routinely
Notes: do not shake or freeze, requires refrigeration

42
Q

What medications are Non-TNF inhibitor biologic DMARDs?

A 
Rituximab (Rituxan)
Anakinra
Abatacept
Tocilizumab
Sarilumab
43
Q

Rituximab MOA, BBW, warnings, administration notes

A

MOA: depletes CD20B cells
BBW: infusion-related reactions, HBV reactivation
Warnings: do not give with other biologic DMARDs or live vaccines
Note: premedicate with a steroid, APAP, and antihistamine

44
Q

Anakinra warnings

A

Malignancies and serious infections

45
Q

Tocilizumab and Sarilumab BBW, and warnings

A

BBW: serious infections
Warnings: do not give with other biologic DMARDs or live vaccines

46
Q

What gender/race is systemic lupus erythematosus (SLE) most common in?

A

Women of african american and asian descent

47
Q

What drugs can cause drug-induced lupus erythematosus (DILE)

A 
Methimazole
Propylthiouracil
Methyldopa
Minocycline
Procainamide
Hydralazine
Anti-TNF agents
Terbinafine
Isoniazid
Quinidine
48
Q

Clinical presentation of SLE

A

Fatigue, depression, anorexia, weight loss, muscle pain, malar rash (butterfly rash), photosensitivity, joint pain and stiffness

49
Q

What percentage of patients with SLE develop lupus nephritis

A

over 50% of patients

50
Q

Drug therapies for SLE

A 
Hydroxychloroquine
Cyclophosphamide
Azathioprine
Mycophenolate mofetil
Cyclosporine
Belimumab (Benlysta)
51
Q

When will a patient with SLE see benefit with systemic therapy?

A

Could take as long as 6 months to see benefit

52
Q

Belimumab (Benlysta) class, MOA, warnings

A

Class: IgG1-lambda monoclonal antibody
MOA: prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocyte stimulator protein to receptor on B lymphocytes, reducing the activity of B-cell mediated immunity and the autoimmune response
Warnings: infections, do not give with other biologic DMARDs

53
Q

Goal for treatment of multiple sclerosis?

A

Prevent disease progression

54
Q

What medications are used for treatment of multiple sclerosis?

A 
Glatiramer acetate
Interferon beta products
Oral immunomodulators
Potassium channel blockers
Monoclonal antibodies
Recombinant humanized monoclonal antibodies
Oral anti-neoplastics
55
Q

Glatiramer acetate indication, warnings, SE, and clinical note

A

Indication: MS
Warnings: Chest pain
SE: Injection site reaction, flushing, diaphoresis, dyspnea
Note: PREFERRED if treatment is required during pregnancy

56
Q

Interferon beta products warnings, SE, which can be given every 14 days?

A

Warnings: psychiatric disorders, injection site necrosis, increased LFTs, thyroid dysfunction (hyper and hypo)
SE: flu-like symptoms
Given every 14 days: Plegridy (pegylated)

57
Q

What oral immunomodulators are used in MS?

A 
Teriflunomide (Aubagio)
Fingolimod (Gilenya)
Dimethyl fumarate (Tecfidera)
Diroximel fumarate (Vumerity)
Siponimod (Mayzent)
58
Q

What potassium channel blockers are used in MS?

A

Dalfampridine (Ampyra)

59
Q

What monoclonal antibodies are used in MS?

A

Natalizumab

60
Q

What recombinant humanized monoclonal antibodies are used in MS?

A

Alemtizumab (Lemtrada, Campath)

Ocrelizumab (Ocrevus)

61
Q

What oral anti-neoplastics are used in MS?

A

Cladribine (Mavenclad)

62
Q

Teriflunomide (Aubagio) CI

A

pregnancy

63
Q

Fingolimod (Gilenya) SE, CI

A

SE: bradycardia (monitor for 6 hours after each dose), macular edema
CI: hx of CVD or stroke

64
Q

Dimethyl fumarate (Tecfidera) and diroximel fumarate (Vumerity) administration notes

A

Do not crush, chew, or sprinkle capsule content onto food

65
Q

Natalizumab (Tysabri) BBW

A

progressive multifocal leukoencephalopathy (PML)

only available through REMS

66
Q

Alemtuzumab (Letrada) BBW

A

Serious, sometimes fatal, autoimmune conditions

REMS program required

67
Q

What medications are used for symptom control in MS?

A 
Anticholinergics for incontinence
Laxatives for constipation
Loperamide for diarrhea
Skeletal muscle relaxants for spasms
Propranolol for tremor
Antidepressants for depression (SNRI if nerve pain)
Modafinil for fatigue
Stimulants for ADHD
Meclizine and scopolamine for dizziness and vertigo
Donepezil for cognitive function
PDE-5 for ED
68
Q

Key counseling points for glatiramer acetate

A

SQ injection
Inject 1-3 times weekly at least 48 hours apart
Can cause injection site reactions, chest pain, SOB and flushing
Store in fridge - can be kept at room temp for 1 month

69
Q

What is raynaud’s phenomenon

A

Common condition triggered by exposure to cold or stress leading to vasospasms in the extremities causing the skin to turn white then blue followed by painful swelling

70
Q

What is commonly used for prevention of raynaud’s phenomenon?

A

CCB - usually nifedipine

71
Q

What medications can cause or worsen Raynaud’s syndrome?

A

Beta blockers
Bleomycin, cisplatin
Sympathomimetics (amphetamines, pseudoephedrine, and illicit drugs)

72
Q

What is celiac disease?

A

Immune response to eating gluten

73
Q

What is gluten? Where is it found?

A

Protein found in wheat, barley, and rye

Can be an excipient in drugs

74
Q

What common excipient indicates a product contains gluten?

A

Starch - if wheat it contains gluten

75
Q

What is myasthenia gravis

A

Autoimmune disease that attacks connections between nerves and muscles, resulting in weakness in skeletal muscles

76
Q

Drugs that can worsen myasthenia gravis

A 
Antibiotics: AG and FQ
Magnesium salts
Antiarrhythmics
Beta blockers
CCB
Antipsychotics
Muscle relaxants
Local anesthetics
77
Q

Myasthenia gravis treatment and warnings of that treatment

A

Cholinesterase inhibitors: block breakdown of acetylcholine, which improves neuromuscular transmission and increases muscle strength
Pyridostigmine (Mestinon)
Warnings: cholinergic effects (SLUDD)

78
Q

What is Sjogren’s syndrome?

A

Autoimmune disease characterized by severe dry eyes and mouth

79
Q

What can be used to treat dry mouth caused by Sjogren’s syndrome?

A 
Muscarinic agonists (pilocarpine or cevimeline)
CI in patients with uncontrolled asthma and narrow-angle glaucoma d/t cholinergic properties and associated side effects
80
Q

Plaque psoriasis appearance and treatment options

A

Raised, red patches covered with a silvery white buildup

Light therapy, topical therapy, and systemic medications

81
Q

How does UV light help psoriasis?

A

Causes activated T cells in the skin to die which slows skin turnover and decreases scaling and inflammation

82
Q

What topical medications are used for psoriasis?

A 
Steroids
Vitamin D analogues (Calcipotriene)
Anthralin
Retinoids
Salicylate
Coal tar
Moisturizers
Calcineurin inhibitors
83
Q

What systemic medications are used for psoriasis?

A

Acitretin
Apremilast (Otezla)
Interleukin receptor antagonists (mAb)

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