Systemic Steroids/Autoimmune

Question 1

Mineralcorticoid Activity

Answer 1

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

Question 2

Glucocorticoid Activity

Answer 2

• 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

Question 3

Cushing’s Syndrome

Answer 3

• 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

Question 4

Addison’s Disease

Answer 4

• Opposite of Cushing’s

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

Question 5

Steroid Dose Equivalence

Answer 5

• 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)

Question 6

DexPak/Decadron

Answer 6

Dexamethasone

Question 7

Solu-Cortef

Answer 7

Hydrocortisone

Question 8

Medrol/Solu-Medrol

Answer 8

Methylprednisolone

-Available as PO dose pack and injection

Question 9

Deltasone

Answer 9

Prednisone

-Prodrug of prednisolone

Question 10

Millipred/Orapred ODT

Answer 10

Prednisolone

Question 11

Kenalog

Answer 11

Triamcinolone

Question 12

Steroid Information

Answer 12

• 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

Question 13

Immunosuppressed Criteria

Answer 13

-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

Question 14

Autoimmune Lab Markers/Sxs

Answer 14

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

Question 15

Strong Immunosuppression Risks

Answer 15

• 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

Question 16

Trexal

Answer 16

• 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)

Question 17

Methotrexate Safety Information

Answer 17

• 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)

Question 18

Plaquenil

Answer 18

• 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

Question 19

Sulfasalazine

Answer 19

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

Question 20

Arava

Answer 20

• Leflunomide
• DMARD
• MoA: inhibits pyrimidine synthesis

Question 21

Leflunomide Safety Information

Answer 21

• 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

Question 22

Drug Elimination Procedures

Answer 22

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

Question 23

JAKi

Answer 23

• 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

Question 24

Anti-TNF DMARDs

Answer 24

• 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

Question 25

Enbrel

Answer 25

- Etanercept - Anti-TNF Biologic DMARD - Can be used +/- MTX - Dosed SQ weekly

Question 26

Humira

Answer 26

- Adalimumab - Anti-TNF Biologic DMARD - Used +/- MTX - Dosed SQ QoWeek

Question 27

Remicade

Answer 27

- 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

Question 28

Cimzia

Answer 28

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

Question 29

Simponi

Answer 29

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

Question 30

Anti-TNF DMARD Information

Answer 30

- 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!)

Question 31

Rituxan

Answer 31

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

Question 32

Rituxan Information

Answer 32

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

Question 33

Kineret

Answer 33

- Anakinra - Biologic DMARD (non-TNF) - Warning: malignancy and serious infection

Question 34

Actemra

Answer 34

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

Question 35

Kevzara

Answer 35

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

Question 36

Conditions that Worsen from Steroids

Answer 36

- Diabetes - HTN - Glaucoma - Psychiatric Conditions