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NAPLEX > Systemic Steroids/Autoimmune > Flashcards

Systemic Steroids/Autoimmune Flashcards

1
Q

Mineralcorticoid Activity

A
  • Ex: fludrocortisone (mimics aldosterone)
  • Used to maintain water/electrolyte balance
  • Used for Addison’s disease and off-label for orthostatic hypotension (helps stabilize BP)
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2
Q

Glucocorticoid Activity

A
  • Ex: prednisone, dexamethasone, hydrocortisone
  • More anti-inflammatory activity
  • Mimics the activity of cortisol
  • Especially when used long term, can cause HPA suppression which causes body to stop making its own cortisol
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3
Q

Cushing’s Syndrome

A
  • Too much cortisol or too high of exogenous steroid doses
  • Glaucoma, acne, moon face, hirsutism, infection/impaired healing, poor bone health, GI bleed
  • Stop steroids abruptly: “Addisonian crisis;” volume depletion, hypotension, potentially fatal
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4
Q

Addison’s Disease

A
  • Opposite of Cushing’s

- Not enough cortisol being made or sudden stop of long-term steroid (HPA suppression)

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5
Q

Steroid Dose Equivalence

A
  • Cortisone: 25 mg (SA) - prodrug of cortisol
  • Hydrocortisone: 20 mg (SA)
  • Prednisone: 5 mg (IA)
  • Prednisolone: 5 mg (IA)
  • Methylprednisolone: 4 mg (IA)
  • Triamcinolone: 4 mg (IA)
  • Dexamethasone: 0.75 mg (LA)
  • Betamethasone: 0.6 mg (LA)
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6
Q

DexPak/Decadron

A

Dexamethasone

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7
Q

Solu-Cortef

A

Hydrocortisone

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8
Q

Medrol/Solu-Medrol

A

Methylprednisolone

-Available as PO dose pack and injection

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9
Q

Deltasone

A

Prednisone

-Prodrug of prednisolone

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10
Q

Millipred/Orapred ODT

A

Prednisolone

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11
Q

Kenalog

A

Triamcinolone

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12
Q

Steroid Information

A
  • Take PO doses with food to decrease GI upset
  • Warning: Adrenal suppression if taken longer than 14 days (taper slowly)
  • SE (short-term): increased appetite/weight gain, emotional instability, insomnia
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13
Q

Immunosuppressed Criteria

A

-Using >= 2mg/kg/d of steroids
OR
-Using >= 20 mg/d of prednisone or equivalent for >2 weeks
Avoid live vaccines and taper when D/C

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14
Q

Autoimmune Lab Markers/Sxs

A
  • Sxs: fatigue, weakness, pain
  • Labs: ESR, CRP, RF, ANA
  • Rheumatoid Arthritis: ACPA and RF
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15
Q

Strong Immunosuppression Risks

A
  • Tuberculosis, Hep B, or C reactivation (test and treat prior to immunosuppressing)
  • Viruses (give live vaccine before treatment if available)
  • Lymphomas and skin cancers
  • Infections
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16
Q

Trexal

A
  • Methotrexate (Also Otrexup, Rasuvo - inj or Xatmep - solution)
  • DMARDs
  • Oral tablet (other brands have SQ/IV options)
  • Inhibits dihydrofolate reductase (decreased folate)
  • Dose: 7.5-20 mg PO Qweek (regardless of route)
  • Use lower doses for RA and NEVER dose daily for RA (liver damage)
17
Q

Methotrexate Safety Information

A
  • Box Warning: myelosuppression, hepatotoxic, mucositis/stomatitis, pregnancy (category X, teratogenic)
  • Monitor: CBCs, LFTs, X-ray, Hep B/C serologies
  • Give folate to decrease hematological/GI/hepatic SE
  • Don’t take with alcohol (increased liver tox. risk)
  • ASA/NSAIDs can decrease its renal elimination (caution)
18
Q

Plaquenil

A
  • Hydroxychloroquine
  • DMARD
  • Generally considered if worried about liver disease in a potential MTX patient
  • Warning: Irreversible retinopathy, N/V/D (food/water)
  • Monitor: eye exam
19
Q

Sulfasalazine

A
  • CI: sulfa OR salicylate allergy
  • Can cause yellow-orange discoloration of skin
  • SE: liver effects, alopecia
20
Q

Arava

A
  • Leflunomide
  • DMARD
  • MoA: inhibits pyrimidine synthesis
21
Q

Leflunomide Safety Information

A
  • Box Warning: DON’T use in pregnancy, hepatotoxic
  • CI: Pregnancy
  • Must have negative preggo test, 2 forms of birth control, wait 2 years after D/C or use accelerated drug elimination procedure before trying to conceive
22
Q

Drug Elimination Procedures

A

Two options used for Leflunomide:

  1. Cholestyramine 8g PO TID x 11d (can decrease to 4g)
  2. Activated charcoal suspension 50g PO Q12H x 11d
23
Q

JAKi

A
  • Inhibits JAK enzymes which stimulate immune cell function
  • Ex: Tofacitinib (Xeljanz), Baricitinib (Olumiant) and Upadacitinib (Rinvoq)
  • DON’T use with DMARDs or potent immunosuppressants
  • Box Warning: Serious infections, malignancy, thrombosis
  • DON’T use with biologic DMARDs or potent immunosuppressors
24
Q

Anti-TNF DMARDs

A
  • Biologic DMARD
  • Inhibits tumor necrosis factor alpha
  • Each drug has pregnancy registry due to unknown risks to fetus (same for non-TNF biologics too)
  • Needles are included with auto-injectors or SQ injection kits (same for non-TNF biologics too)
  • Add-on therapies to MTX; however, can be initial therapy WITH MTX if severe
  • DILE and HF causers
25
Q

Enbrel

A
  • Etanercept
  • Anti-TNF Biologic DMARD
  • Can be used +/- MTX
  • Dosed SQ weekly
26
Q

Humira

A
  • Adalimumab
  • Anti-TNF Biologic DMARD
  • Used +/- MTX
  • Dosed SQ QoWeek
27
Q

Remicade

A
  • Infliximab
  • Anti-TNF Biologic DMARD
  • MUST be used with MTX
  • Given IV at certain weeks and then Q8W
  • NS stable ONLY
  • Infusion Rxn: hypotension, fever, chills, pruritis (pre-med = APAP, antihistamines, steroids)
  • Delayed hypersensitivity rxn 3-12d after administration
28
Q

Cimzia

A
  • Certolizumab
  • Anti-TNF Biologic DMARD
  • Used +/- MTX
  • Dosed SQ QoWeek
  • Administer at 45 degree angle!
29
Q

Simponi

A
  • Golimumab
  • Anti-TNF Biologic DMARD
  • MUST use with MTX
  • Dosed Sq QMonth
  • Requires a filter for use
30
Q

Anti-TNF DMARD Information

A
  • Box Warning: Serious infection, TB reactivation, malignancies
  • Warning: demyelination disease, hep B reactivation, HF, hepatotoxic, lupus-like syndrome (DILE!)
  • Do NOT use with other biologic DMARDs or live vaccines
  • Do not shake or freeze: refrigerate! - leave out for 15-30 minutes before injecting (2nd click!)
31
Q

Rituxan

A
  • Rituximab
  • Biologic DMARD (non-TNF)
  • MUST use with MTX
  • Depletes CD20 B cells
  • Pre-medicate with steroid, APAP, and antihistamine!
32
Q

Rituxan Information

A
  • Box warning: infusion-related rxn (premedicate req!), HBV reactivation, SJS/TEN
  • Do NOT give with other biologic DMARDs or live vaccines
33
Q

Kineret

A
  • Anakinra
  • Biologic DMARD (non-TNF)
  • Warning: malignancy and serious infection
34
Q

Actemra

A
  • Tocilizumab
  • Biologic DMARD (non-TNF)
  • Box warning: infections, screen for TB
  • Do NOT give with other biologic DMARDs or live vaccines
35
Q

Kevzara

A
  • Sarilumab
  • Biologic DMARD (non-TNF)
  • Box warning: infections, screen for TB
  • Do NOT give with other biologic DMARDs or live vaccines
36
Q

Conditions that Worsen from Steroids

A
  • Diabetes
  • HTN
  • Glaucoma
  • Psychiatric Conditions

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