Systemic Steroids and Autoimmune Conditions Flashcards
Which is safer - long-term use of NSAIDs or long-term use of steroids?
NSAIDs
If there is a lack of cortisol what steroids can be given to supplement?
Any
If there is a lack of aldosterone, which steroids can be given to supplement?
Fludrocortisone
What is fludrocortisone FDA approved for? What is it used off label for?
FDA approved for Adidson’s disease
Off-label for orthostatic hypotension
Fludrocortisone mineralocorticoid or glucocorticoid activity
mineralocorticoid activity which is used to maintain balance of water and electrolytes
Which has anti-inflammatory effects, steroids with mineralocorticoid or glucocorticoid activity?
Glucocorticoid
Why do steroids need to be tapered?
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
Cushing’s syndrome pathophys
Adrenal gland produces too much cortisol
***Can also occur when steroids are taken in high doses
Addison’s disease pathophys
Adrenal gland produces not enough cortisol
***Can happen if on steroids long term and they are stopped suddenly and not tapered
What are long-term effects of steroids
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
Which steroids are short acting? Intermediate? Long?
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)
Steroids least potent to most potent
Cute Hot Pharmacists and Physicians Marry Together and Deliver Babies Cortisone Hydrocortisone Prednisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone
Glucocorticoids warnings, SE
Warnings: adrenal suppression - must taper slowly
SE: (short term) increased appetite, weight gain, emotional instability, insomnia, GI upset - take with food
What is cortisone the prodrug of?
Cortisol
What is prednisone the prodrug of?
Prednisolone
Dexamethasone brand name
DexPak 6, 10, or 13 day
Decadron
Hydrocortisone brand name
Solu-Cortef
Methylprednisolone brand name
Medrol
Solu-Medrol
Prednisone brand name
Deltasone
Prednisolone brand name
Millipred
Orapred ODT
Triamcinolone brand name
Kenalog
A patient is considered immunosuppressed when receiving ____ or more mg/kg/d or > ____ mg/d of prednisone or equivalent for > 2 weeks
2 mg/kg/d
20 mg/d
What dose of each of the following is equivalent to 20mg of prednisone Cortisone Hydrocortisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone
Cortisone - 100mg Hydrocortisone - 80mg Prednisolone - 20 mg Methylprednisolone - 16 mg Triamcinolone - 16 mg Dexamethasone - 3 mg Betamethasone - 2.4 mg
Use of strong immunosuppressants can increase risk of certain conditions including what?
Reactivation of tuberculosis and hepatitis B and C
Viruses
Lymphomas and certain skin cancers
Infections
Clinical presentation of rheumatoid arthritis (RA)
Bilateral, symmetrical symptoms
Joint swelling, pain, stiffness
Bone deformity
“Morning stiffness” or stiffness that is worse after rest
What lab tests can be used to diagnose RA?
Anti-citrullinated peptide antibody (ACPA) Rheumatoid factor (RF)
What is first-line treatment for someone with RA?
Disease-modifying antirheumatic drug (DMARD)
Methotrexate is DOC
What medications are DMARDs?
Methotrexate
What is treatment of choice in someone with RA that is not managed with MTX alone?
DMARD or tumor necrosis factor (TNF) or non-TNF biologic
+/- MTX
Why should 2 biologic DMARDs never be used together?
risk of serious (fatal) infections
Steroids commonly used in RA flares should be used at the ___ dose and for the ___ amount of time
Lowest dose
Shortest amount of time
Methotrexate (Trexall) MOA, BBW, monitoring
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
What can be given to decrease hematological, GI, and hepatic side effects of MTX?
Folate
Hydroxychloroquine (Plaquenil) warnings
Irreversible retinopathy
How is MTX dosed in RA?
Low, once weekly dose (7.5-20mg)
Sulfasalazine CI
Sulfa or salacylate allergy
Leflunomide MOA, BBW, counseling note
MOA: inhibits pyrimidine synthesis
BBW: do not use in pregnancy, hepatotoxicity
Must wait 2 years after d/c to become pregnant
What medications are janus kinase inhibitors?
Tofacitinib
Baricitinib
Upadacitinib (Rinvoq)
Janus Kinase Inhibitor BBW and notes
BBW: serious infections, increased risk of malignancy, increased risk of thrombosis
Do NOT use with biologic DMARDs
What medications are Anti-TNF biologic DMARDs?
Entercept (Enbrel) Adalimumab (Humira) Infliximab (Remicade) Certolizumab pegol (Cimzia) Golimumab (Simponi)
Anti-TNF biologic DMARD BBW, warnings, monitoring, counseling notes
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
What medications are Non-TNF inhibitor biologic DMARDs?
Rituximab (Rituxan) Anakinra Abatacept Tocilizumab Sarilumab
Rituximab MOA, BBW, warnings, administration notes
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
Anakinra warnings
Malignancies and serious infections
Tocilizumab and Sarilumab BBW, and warnings
BBW: serious infections
Warnings: do not give with other biologic DMARDs or live vaccines
What gender/race is systemic lupus erythematosus (SLE) most common in?
Women of african american and asian descent
What drugs can cause drug-induced lupus erythematosus (DILE)
Methimazole Propylthiouracil Methyldopa Minocycline Procainamide Hydralazine Anti-TNF agents Terbinafine Isoniazid Quinidine
Clinical presentation of SLE
Fatigue, depression, anorexia, weight loss, muscle pain, malar rash (butterfly rash), photosensitivity, joint pain and stiffness
What percentage of patients with SLE develop lupus nephritis
over 50% of patients
Drug therapies for SLE
Hydroxychloroquine Cyclophosphamide Azathioprine Mycophenolate mofetil Cyclosporine Belimumab (Benlysta)
When will a patient with SLE see benefit with systemic therapy?
Could take as long as 6 months to see benefit
Belimumab (Benlysta) class, MOA, warnings
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
Goal for treatment of multiple sclerosis?
Prevent disease progression
What medications are used for treatment of multiple sclerosis?
Glatiramer acetate Interferon beta products Oral immunomodulators Potassium channel blockers Monoclonal antibodies Recombinant humanized monoclonal antibodies Oral anti-neoplastics
Glatiramer acetate indication, warnings, SE, and clinical note
Indication: MS
Warnings: Chest pain
SE: Injection site reaction, flushing, diaphoresis, dyspnea
Note: PREFERRED if treatment is required during pregnancy
Interferon beta products warnings, SE, which can be given every 14 days?
Warnings: psychiatric disorders, injection site necrosis, increased LFTs, thyroid dysfunction (hyper and hypo)
SE: flu-like symptoms
Given every 14 days: Plegridy (pegylated)
What oral immunomodulators are used in MS?
Teriflunomide (Aubagio) Fingolimod (Gilenya) Dimethyl fumarate (Tecfidera) Diroximel fumarate (Vumerity) Siponimod (Mayzent)
What potassium channel blockers are used in MS?
Dalfampridine (Ampyra)
What monoclonal antibodies are used in MS?
Natalizumab
What recombinant humanized monoclonal antibodies are used in MS?
Alemtizumab (Lemtrada, Campath)
Ocrelizumab (Ocrevus)
What oral anti-neoplastics are used in MS?
Cladribine (Mavenclad)
Teriflunomide (Aubagio) CI
pregnancy
Fingolimod (Gilenya) SE, CI
SE: bradycardia (monitor for 6 hours after each dose), macular edema
CI: hx of CVD or stroke
Dimethyl fumarate (Tecfidera) and diroximel fumarate (Vumerity) administration notes
Do not crush, chew, or sprinkle capsule content onto food
Natalizumab (Tysabri) BBW
progressive multifocal leukoencephalopathy (PML)
only available through REMS
Alemtuzumab (Letrada) BBW
Serious, sometimes fatal, autoimmune conditions
REMS program required
What medications are used for symptom control in MS?
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
Key counseling points for glatiramer acetate
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
What is raynaud’s phenomenon
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
What is commonly used for prevention of raynaud’s phenomenon?
CCB - usually nifedipine
What medications can cause or worsen Raynaud’s syndrome?
Beta blockers
Bleomycin, cisplatin
Sympathomimetics (amphetamines, pseudoephedrine, and illicit drugs)
What is celiac disease?
Immune response to eating gluten
What is gluten? Where is it found?
Protein found in wheat, barley, and rye
Can be an excipient in drugs
What common excipient indicates a product contains gluten?
Starch - if wheat it contains gluten
What is myasthenia gravis
Autoimmune disease that attacks connections between nerves and muscles, resulting in weakness in skeletal muscles
Drugs that can worsen myasthenia gravis
Antibiotics: AG and FQ Magnesium salts Antiarrhythmics Beta blockers CCB Antipsychotics Muscle relaxants Local anesthetics
Myasthenia gravis treatment and warnings of that treatment
Cholinesterase inhibitors: block breakdown of acetylcholine, which improves neuromuscular transmission and increases muscle strength
Pyridostigmine (Mestinon)
Warnings: cholinergic effects (SLUDD)
What is Sjogren’s syndrome?
Autoimmune disease characterized by severe dry eyes and mouth
What can be used to treat dry mouth caused by Sjogren’s syndrome?
Muscarinic agonists (pilocarpine or cevimeline) CI in patients with uncontrolled asthma and narrow-angle glaucoma d/t cholinergic properties and associated side effects
Plaque psoriasis appearance and treatment options
Raised, red patches covered with a silvery white buildup
Light therapy, topical therapy, and systemic medications
How does UV light help psoriasis?
Causes activated T cells in the skin to die which slows skin turnover and decreases scaling and inflammation
What topical medications are used for psoriasis?
Steroids Vitamin D analogues (Calcipotriene) Anthralin Retinoids Salicylate Coal tar Moisturizers Calcineurin inhibitors
What systemic medications are used for psoriasis?
Acitretin
Apremilast (Otezla)
Interleukin receptor antagonists (mAb)
