Systemic Steroids & Autoimmune Conditions Flashcards
1
Q
What 2 endogenous hormones might require replacement?
A
Cortisol: glucocorticoid (anti-inflammatory)
Aldosterone: mineralocorticoid (water and electrolyte balance/BP)
2
Q
What steroid is used to replace aldosterone? What is this steroid used to treat?
A
- Fludrocortisone (mineralcorticoid)
- Addison’s disease/ Orthostatic hypotension
3
Q
Why do steroids need tapered off?
A
Suppressing the HPA axis causes the adrenal gland to stop producing cortisol
4
Q
What is Cushing’s Syndrome?
A
Side effects that result from over production of cortisol or high dose exogenous steroids
5
Q
What are s/sx of Cushing’s Syndrome/long-term systemic steroid use?
A
- Psychiatric changes, intracranial hypertension
- Glaucoma/cataracts
- Acne, fat deposits in the face (moon face)
- Hypothyroidism, DM, fat deposits in abdomen/upper back (buffalo hump)
- GI bleeding, esophagitis, ulcers
- Stretch marks (striae) on abdomen/thighs/breasts/arms
- Muscle wasting (thin arms/legs), growth retardation
- Infection/impaired wound healing, poor bone health/fracture
- Hair growth on face/body, irregular/absent menstrual cycle (women)
6
Q
What is Addison’s Disease/Addisonian Crisis?
A
Addison’s: the body does not make enough cortisol
Crisis: abrupt D/C of steroids (volume depletion, hypotension, can be fatal)
7
Q
What are strategies to reduce systemic steroid risk?
A
- Every other day dosing
- Steroids with low systemic absorption for GI conditions: budesonide DR (Entocort ER)
- Lowest effective dose for shortest time
- Inhaled steroids for asthma/ intra-articular for arthritis (avoid systemic when possible)
8
Q
List systemic steroids (PO/IV) in order of least to most potent (also shortest to longest acting)
A
Cortisone 25mg
Hydrocortisone 20mg
Prednisone 5mg
Prednisolone 5mg
Methylprednisolone 4mg
Triamcinolone 4mg
Dexamethasone 0.75mg
Betamethasone 0.6mg
Cute Hot Pharmacists/Physicians Marry To Deliver Babies
9
Q
Dexamethasone
A
Decadron
DexPak 6/10/13
Dexamethasone Intensol
10
Q
Hydorcortisone
A
Solu-Cortef
Cortef
Alkindi Sprinkle
11
Q
Methylprednisolone
A
Medrol
Solu-Medrol
Depo-Medrol
12
Q
Prednisone
A
Deltasone
Prednisone Intensol
Rayos
13
Q
Prednisolone
A
Millipred
Orapred ODT
14
Q
Triamcinolone
A
Kenalog
Pro-C-Dure Kits
15
Q
Betamethasone
A
Celestone Soluspan
16
Q
What are CIs to using systemic steroids?
A
- live vaccines
- serious systemic infections
17
Q
What are warnings with systemic steroids?
A
- Adrenal Suppression: taper if taking >14 days
- Immunosuppression, Kaposi sarcoma
- psychiatric disturbances
- worsened HF/DM/HTN/osteoporosis
18
Q
What are short term SEs with systemic steroids (<1 month)?
A
- Fluid retention
- Stomach upset
- Emotional instability (euphoria, mood swings, irritability)
- Insomnia
- Increased appetite/ Weight gain
- Elevated BG/BP
19
Q
What should be monitored with systenic steroids?
A
- BP/BG
- weight
- mood
- bone mineral density
- electrolytes
- infection
- growth (children)
- IOP (>6 weeks)
20
Q
What are counseling points for systemic steroid administration?
A
- QD dosing: take at 7-8 am to mimic natural diurnal cortisol
- Take PO doses with food to reduce GI upset
21
Q
What steroids are prodrugs?
A
- Cortisone is the prodrug of Cortisol
- Prednisone is the prodrug of Prednisolone
22
Q
What steroid is preferred in children due to a wide variety of dosage forms?
A
Prednisolone
23
Q
When does someone on systemic steroids become immunosuppressed?
A
≥2mg/kg/day or ≥20mg/day of Prednosine/ Prednisone equivalent for >2 weeks (14 days )
24
Q
What should be avoided in patients who are immunosuppressed on long term steroids?
A
- Avoid live vaccines, high risk of infection
- Must taper steroids
25
How should steroids be tapered?
1. High dose initially, then taper every day (acute steroids)
2. Reduce dose by 10-20% every few days (long-term)
26
What are the risks of using steroids/drugs to cause immunosuppression for autoimmune conditions?
1. Reactivations of TB or HepatitisB/C: testing/ treatment required before starting tx
2. Viruses: administer live vaccines before tx
3. Lymphomas/skin cancers: usually suppressed by the immune system
4. Infections: monitor for s/sx of bacterial/fungal infections and CBC
27
What are s/sx of an autoimmune disease?
1. Fatigue/Weakness
2. Pain
3. erythrocyte sedimentation rate (ESR)
4. C-reactive Protein
5. Rheumatoid factor (RF)
6. Anti-nuclear antibody (ANA)
28
What are s/sx of RA?
1. Bilateral/Symmetrical inflammation with Pain
2. Worst after rest/ "morning stiffness"
3. Anti-citullinated peptide antibody
4. RF (low specificity)
5. Joint swelling/ Bone deformity
6. weakness/difficulty moving
7. edema/redness
29
What is first line tx for RA?
Methotrexate +/- ≤10mg/day prednisone or equivalent and NSAIDs for bridge therapy
30
What drugs are used to treat RA?
1. non biologic DMARDS
2. Anti-TNF biologics
3. Non-TNF biologics
31
What are traditional disease-modifying antirheumatic drugs (DMARDs)?
Immune Modulations:
1. Methotrexate (MTX)
2. Hydroxychloroquine +/- MTX
3. Sulfasalazine +/- MTX
4. Leflunomide +/- MTX
5. JAK inhibitors +/- MTX
32
Methotrexate
Trexall (Oral tablet)
Otrexup (SC-auto injector)
Rasuvo (SC-auto injector)
Xatmep (oral solution-peds)
33
Hydroxycholoroquine
Plaquenil
34
Sulfasalazine
Azulfidine
Azulfidine EN-tabs
35
Leflunomide
Arava
36
What is the MOA of Methotrexate?
Irreversibly binds and inhibits dihydrofolate reductase, inhibiting folate; anti inflammatory/immune modulating activity
37
What are BBWs for MTX?
1. Hepatotoxicity
2. Myelosuppression
3. Mucositis/stomatitis
4. Avoid in Pregnancy
5. acute renal failure
6. pneumonitis (inflamm/irritation of the lungs
7. GI toxicity
8. malignant lymphomas/ potentially fatal OI
9. dermatologic reactions
10. renal/lung toxicity when using high oncology dosing
38
What are CIs to using MTX?
1. Pregnancy
2. breastfeeding
3. alcohol use disorder
4. chronic liver disease
5. blood dyscrasias
6. immunodeficiency syndrome
39
What are SEs with MTX?
1. N/V/D
2. elevated LFTs
3. stomatitis (irritation of skin around lips/mouth)
4. photosensitivity
5. arthalgia/myalgia
40
What should be monitored with MTX?
1. CBC
2. LFT (baseline every 2-4 wk for 3 mo, every 8-12 wk for 3-6 mo, then less frequently)
3. Chest X-ray
4. Hepatitis B/C serologies (if at risk)/ TB test
5. SCr
6. PFTs (if lung related symptoms)
41
What can be given to decrease hematologic, GI, and hepatic SEs with MTX? How is it dosed?
Folate 5mg PO weekly on the day following MTX administration or 1mg on non-MTX days
42
How is MTX doses for RA?
7.5-20mg once weekly PO/SC/IM as a single dose
43
How/where is SQ MTX administered?
Administer in abdomen and thighs via auto injector Otrexupa (do not have to inch skin)
and Rasuvo (must pinch skin)
44
What are DIs with MTX?
1. DO NOT TAKE WITH ALCOHOL increased liver toxicity
2. Reduced renal elimination with aspirin/NSAIDs
3. sulfonamides and tpoical tcrolimus increases SEs
4. decrease effectiveness of loop diuretics and increase concentration of MTX
5. increased levels of both MTX and cyclosporine when used together
45
What are the warnings with Hydroxychloroquine?
1. Irreversible retinopathy
2. QT prolongation/cardiomyopathy
3. neuropathy/myopathy
4. hypoglycemia
5. psychiatric events (suicidal behavior)
6. renal toxicity (phospholipids maybe)
46
What are SEs with Hydroxychloroquine?
1. Vision changes (dose -related)
2. N/V/D/ab pain
3. rash/pruritus
4. bone marrow suppression (leukopenia/anemia/thrombocytopenia)
5. headache
6. pigmentation changes of the skin/hair (rare)
7. hepatotoxicity
8. hemolysis in pt with G6PD deficiency
47
What should be monitored with Hydroxychloroquine?
1. CBC
2. LFTs (lower risk of hepatotoxicity vs. MTX; use if concern for liver disease)
3. ECG; baseline and periodically
4. Eye exam and muscle strength at baseline every 3 mo during prolonged therapy
48
How is Hydroxycholoquine dosed/administered?
1. Take with food
2. use as mono therapy is low disease activity and sx < 24 mo
3. consider alternative if no response in mo
4. 400-600 mg/day initially then 200-400 mg/day maintenance
49
What are CIs to using sulfasalazine?
1. Sulfa/ Salicylate allergy
2. GI/GU obstruction
3. porphyria (group of rare genetic disorders that affect how the body produces heme, a component of hemoglobin)
50
What are warnings with sulfasalazine?
1. blood dyscrasias
2. severe skin reactions (SJS/TENS)
3. hepatic failure
4. pulmonary fibrosis
5. caution in pt with G6PD deficiency
51
What are SEs with sulfasalazine?
1. headache
2. rash
3. anorexia
4. N/V/D/dyspepsia
5. oligospermia (low sperm count; reversible)
6. arthalgia
7. crystaluria
8. folate deficiency
9. YELLOW/ORANGE SKIN/URINE
52
What should be monitored with sulfasalazine?
1. CBC
2. LFTs (baseline, every other week for 3 mo then once every 3 mo)
3. renal function
53
How should sulfasalazine be administered? What are counseling pints?
1. Discolors skin/urine yellow-orange
2. Take with food and 8oz water to prevent crystaluria
3. 1mg/day supplement impairs folate absorption
4. Max 3g/day
54
What is the MOA of leflunomide?
Inhibits pyrimidine synthesis resulting in anti-prolifirative/inflammatory effects; prodrug of teriflunomide
55
What are BBWs with leflunomide?
1. DO NOT USE IN PREGNANCY; must test and rule out pregnancy prior to tx
2. Hepatotoxicity: avoid in pre-existing liver disease or ALT >2x ULN
56
What are CIs with Leflunomide?
1. Pregnancy
2. severe hepatic impairment
3. current teriflunomide tx
57
What are warnings with leflunomide?
1. severe infection
2. serious skin reaction (SJS/TENS)
3. peripheral neuropathy
4. interstitial lung disease
5. HTN
6. if D/C follow accelerated procedure
58
What are SEs with leflunomide?
1. Elelvated LFTs
2. N/D
3. respiratory infections
4. rash
5. headache
59
What are accelerated drug elimination options for leflunomide?
1. cholestyramine 8g PO TID x 11 days (use 4 g dose if 8g not tolerated)
2. Activated charcoal sus. 50g PO Q12H x 11 days
60
What are counseling points for administration of leflunomide?
Must have a negative pregnancy test and use 2 forms of BC during tx; if pregnancy is desired, must wait 2 yr after D/C or use accelerated drug elimination procedure
61
What is the MOA of Jak inhibitors?
inhibits the Janus kinase enzymes, which stimulate immune cell function
62
What are BBWs with Jak Inhibitors?
1. Serious infections: TB, fungal, bacterial, or OI; screen for active/latent TB before staring
2. Malignancy: increase risk of lymphomas
3. Thrombosis: increase risk of serious/ fatal blood clots including PE, DVT, arterial thrombosis
4. mortality/majorrisk of CV events: increase risk in pt ≥50 yr with ≥1CV RF
63
What are warnings with Jak inhibitors?
1. GI perforation
2. elevated LFTs
3. hematologic toxicities
4. Avoid live vaccines
64
What are SEs with Jak inhibitors?
1. URTIs
2. UTIs
3. diarrhea
4. HTN
5. elevated lipids
6. headache
65
What should be monitored with Jak inhibitors?
1. CBC (for lymphoma, neutropenia, anemia)
2. lipids (baseline, 4-8 weeks, then every 3 mo)
3. LFTs (baseline and periodically)
4. new-onset abdominal pain
5. signs of infection
6. Avoid use of biologic DMARDs
7. Caution in Asians (increased SEs)
66
Tofacitnib
Xeljanz
Xeljanz XR
67
Barcitnib
Olumiant
68
Upacitnib
Rinvoq
69
How is tofacitnib (Xeljanz) dosed?
1. Do not start if absolute lymphocyte count <500, Hgb <9, or ANC<1000
2. Dose adjustment required with moderate-strong CYP3A4 inducers and hepatic/renal impairment
3. IR: 5mg PO BID
4. XR: 11mg PO QD
70
How is barcitnib (Olumiant) dosed?
1. Do not start if absolute lymphocyte count <500, Hgb <8, or ANC<1000
2. GFR <30 not recommended
3. 2mg PO QD
71
How is upadacitnib (Rinvoq) dosed?
1. Do not start if absolute lymphocyte count <500, Hgb <8, or ANC<1000
2. 15mg QD
72
Entanercept
Enbrel
Erelzi (biosimilar)
Etocovo (biosimilar)
73
Adalimumab
Humira
Humira Pen
Abrilada (biosimilar)
Amjevita (biosimilar)
Cyltezo (biosimilar)
Hadlima (biosimilar)
Hulio (biosimilar)
Hyrimoz (biosimilar)
Idacio (biosimilar)
Yuflyma (biosimilar)
Yusimry (biosimilar)
74
Infliximab
Remicade
Avsola (biosimilar)
Renflexis (biosimilar)
Inflectra (biosimilar)
Ixifi (biosimilar)
75
Certolizumab pegol
Cimzia
Cimzia Starter Kit
76
Golimumab
Simponi
Simponi Aria
77
What is the MOA if anti-TNF biologics?
Inhibits tumor necrosis factor alpha; each drug has a pregnancy registry to track risks to the fetus
78
What are BBWs with anti-TNF biologics?
1. Serious infections (can be fatal, TB, fungal, viral, bacterial, OIs)
2. Screen for latent TB and tx before starting biologic
3. Malignancy/lymphoma
79
What are CIs with anti-TNF biologics?
1. Active systemic infection
2. >5mg/kg doses in those with moderate-severe HF (infliximab)
3. sepsis (entanercept)
80
What are warnings with anti-TNF biologics?
Can cause:
1. Demyelinating disease
2. Hepatitis B reactivation
3. HF
4. Hepatotoxicity
5. Lupus-like syndrome
6. seizures
7. myelosuppression
8. severe infection
9. DO NOT USE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINES
81
What are SEs with anti-TNF biologics?
1. infections
2. inj site reactions (rash, swelling, itching, bruising)
3. pos anti-nuclear antibodies (antibody induction)
4. headache
5. nausea
6. elevated CPK (adalimumab )
82
What is monitored with anti-TNF biologics?
Proir to starting:
1. TB test; treat if pos before starting tx
2. HBV
Routine:
1. Signs of infection
2. CBC
3. LFTs
4. HBV
5. TB (annually if RFs)
6. sx of HF
7. malignancies
8. vitals (IV infliximab)
83
What is the role of anti-TNF biologics in RA?
MTX is 1st line and anti-TNF biologics are add-on; may be started as initial therapy with severe initial presentation
84
How are anti-TNF biologics stored?
1. DO NOT shake/freeze
2. Refrigeration required (will denature of hot)
3. Allow to come to room temperature (15-30 min) before inj
4. Entanercept and Adalimumab: stable at room temperature for 14 days; do not refrigerate once warmed
85
How is Entanercept administered?
90 deg SQ inj weekly
86
How is adalimumab administered?
90 deg SQ inj every other week
87
How is infliximab administered?
IV infusion at week 0, 2, 6, then every 8 wk; requires a filter and NS only
88
What additional SEs does infliximab infusion have?
1. Infusion reactions (hypotension, fever, chills, itch; can premedicate with tylenol, antihistamine, steroids)
2. Delayed HSR 3-12 days after administration (fever, rash, myalgia, headache, sore throat)
89
How is certolizumab pegol administered?
45 deg SQ inj every other wk
90
How is golimumab administered?
1. 90 deg SQ inj monthly
2. IV infusion over 30 min at week 0, 4, then every 8 weeks; requires a filter
91
Rituximab
Rituxan
Riabni (biosimilar)
Ruxience (biosimilar)
Truxima (biosimilar)
92
Anakinra
Kineret
93
Abatacept
Orencia
Orencia ClickJect
94
Tocilizumab
Actemra
Actemra ACTPen
95
Sarilumab
Kevzara
96
What is the MOA of rituximab?
Depletes CD20 B cells
97
What are BBWs with rituximab?
1. Serioud/fatal infusion related rxn (usually with 1st tx)
2. progressive multifocal leukoencephalopathy due to JC virus
3. serious skin reaction (SJS/TENS)
4. HBV reactivation (screen those at high risk for HCV/HBV prior to initiating) several mo after treatment
98
What are warnings with rituximab?
1. infections
2. DO NOT GIVE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINES
99
What are SEs with rituximab?
RA:
1. infusion reactions
2. URTIs
3. UTIs
4. N/V/D
5. peripheral edema/angioedema/ weight gain
6. HTN
7. headache
8. fever
9. insomnia
10. pain
100
What should be monitored with rituximab?
1. ECG
2. vitals
3. infusion rxn
4. CBC
5. SCr
6. electrolytes
7. HBV screening before
101
How is rituximab dosed/administered?
1. MUST PREMEDICATE with steroid, tylenol, and antihistamine (all 3)
2. IV on day 1 and 15 (IN COMBINATION WITH MTX DOSES) can repeat in 16-24wk
3. invert bag to mix, do not shake
4. max 400mg/h
102
What is the MOA of anakinra?
IL-1 rec antagonist
103
What are warnings with anakinra?
1. Malignancy
2. Serioud infection; D/C if inf
3. Screen for TB prior to start
4. DO NOT GIVE WITH OTHER BIOLOGICS/LIVE VACCINES
104
What are SEs with anakinra?
1. URTIs
2. headache
3. N/D/ ab pain
4. inj site rxn
5. antibody development
6. arthralgias
105
What should be monitored with anakinra?
1. CBC
2. SCr
3. s/sx inf
106
How is anakinra dosed/administered/stored?
1. Do not shake/ freeze
2. Refrigerate and Protect from light
3. SQ QD (same time each day)
4. CrCl<30: every other day
5. Use only after failure of 1 or more DMARDs
107
What is the MOA of abatacept?
inhibits T cell activation by binding to CD80 and CD86 on antigen presenting cella
108
What are warnings with abatacept
1. Malignancy
2. Serioud infection; D/C if inf
3. Screen for TB prior to start
4. DO NOT GIVE WITH OTHER BIOLOGICS/LIVE VACCINES
5. May worsen COPD, use caution
109
What are SEs with abatacept?
1. headache
2. nausea
3. inj site rxn
4. infections
5. nasopharyngitis
6. antobody development
110
What should be monitored with abatacept?
1. s/sx infection
2. HSR
111
How is abatacept dosed/administered/stored?
1. IV at week 0, 2, 4 then every 4 weeks infused over 30 min
2. SQ weekly (must have IV LD then SQ within 24h, then dose SQ weekly)
3. NS only
4. Requires a filter and light protection during administration
5. Do not shake
112
What is the MOA of tolicilizumab/sarilumab?
IL-6 rec antagonist
113
What are BBWs with tolicilizumab/sarilumab?
1. Serioud infection, D/C if inf
2. Screen for TB prior to start
114
What are warnings with tolicilizumab/sarilumab?
1. Elevated LFTs
2. neutropenia/ thrombocytopenia
3. GI perforation
4. demylinating disease
5. HSR
6. lipid abnormalities
7. DO NOT GIVE WITH OTHER BIOLOGICS/LIVE VACCINES
115
What are SEs with tolicilizumab/sarilumab?
1. URTIs
2. headache
3. HTN
4. inj site rxn
5. Elevated LDL/TC
116
What should be monitored with tolicilizumab/sarilumab?
1. LFT (Do not start if ALT/AST >1.5x ULN, ANC<2000, or platelets<100000)
2. CBC (baseline, 4-8 weeks after start, and every 3 mo)
3. lipid pannel
4. s/sx inf
117
How is tolicilizumab dosed/administered/stored?
1. IV every 4wk over 60 min (max dose: 800mg)
2. SQ every other wk (<100kg) or SQ weekly (≥100kg)
3. Do not use SQ product for IV, contains polysorbate 80
118
How is sarilumab dosed/administered/stored?
SQ every 2 weeks
119
Which biologics (TNF and non-TNF) MUST be given with MTX?
1. Infliximab (Remicade)
2. Golimumab (Simponi)
3. Rituximab (Rituxan)
120
Where are most SQ biologic DMARDs administered?
1. Abdomen/upper thigh
2. Upper arm (Simponi, Enbrel)
3. Needles included in auto injector device
121
What are s/sx of lupus?
1. Photosensitivity/ butterfly rash
2. Fatigue
3. Depression
4. Anorexia/Weight loss
5. Muscle/Joint pain/stiffness
6. Hematologic
7. Renal/Lupus nephritis
8. Neurologic
9. Anti-ssDNA/ Anti-dsDNA
10. Antinuclear antibody (not sensitive)
122
What drugs can cause Lupus?
1. Methyldopa
2. Propylthiouracil
3. Methimazole
4. Procainamide (used in AA population)
5. Hydralazine (also in BiDil; used in AA population)
6. Anti-TNF agents
7. Terbinafine
8. Isoniazid
9. Quinidine
My Pretty Misty May Pony Probably Had A Time In Queensland
123
What non-drug treatmant in inportant for SLE?
Sunscreen, Sun protection/avoidance
124
What drugs are FDA-approved to treat SLE?
1. Hydroxychloroquine (Plaquenil)
2. Anifrolumab (Saphnelo)
3. Belimumab (Benlysta; also lupus nephritis)
4. Voclosporin (Lupkynis; lupus nephritis only)
125
What immunosuppressants can be used alone or in combination for chronic SLE tx?
1. Hydroxychloroquine (Plaquenil)
2. Cyclophosphamide
3. Azathioprine
4. Mycophenolate mofetil
5. Cyclosporine
126
How long can it take for chronic SLE therapy to have an effect?
Up to 6 months
127
What is the MOA of belimumab for SLE?
IgG1-lambda monoclonal antibody: prevents survival of B lymphocytes by blocking the binding of soluble B lymphocyte simulator protein (BLyS) to rec on B lymphocytes, reducing activity of B-cell mediated immunity and autoimmune response
128
What are the warnings with belimumab?
1. Serious/fatal infections
2. PML
3. acute HSR
4. malignancy
5. psychiatric events
6. DO NOT GIVE WITH BIOLOGIC DMARDS OR LIVE VACCINES
7. CAUTION in pregnancy crosses the placenta
8. African Americans have lower response rate, caution
129
What are SEs with belimumab?
1. N/D
2. fever
3. depression (suicidal ideation)
4. Insomnia
130
How is belimumab dosed?
1. IV every 2wk x 3 doses then every 4 wk after, infused over 1 h; premedication should be considered for HSR
2. SC weekly
131
Belimumab
Benlysta
132
What is the MOA of Vocosporin?
Calceneurin inhibitor: supresses immune system by inhibiting T lymphocyte activation
133
What are BBWs with Vocosporin?
1. Serious/fatal infection
2. Malignancy
134
What are warnings with Vocosporin?
1. Nephrotoxicity
2. HTN
3. QT prolongation
4. Hyperkalemia
5. neurotoxicity
6. red cell aplasia
7. DO NOT GIVE WITH LIVE VACCINES
8. Avoid in pregnancy; breast feeding not recommended by manufacturer
135
What are SEs with Vocosporin?
1. HTN
2. Diarrhea/ab pain/dyspepsia
3. Headache
4. Renal impairment
5. anemia
6. cough
7. UTI
8. fatigue
136
How is Vocosporin dosed/administered?
PO BID in combination with steroids and mycophenolate
137
Vocosporin
Lupkynis
138
What are s/sx of MS?
1. Fatigue
2. Numbness
3. Blurry vision
4. Cognitive decline
5. Bladder spasticity
6. Gait instability
7. heat sensitivity
139
How is MS dx and what is the goal of therapy?
MRI; prevent disease pregression, permanent loss
140
What are the disease-modifying therapies for MS?
1. Interferon beta formulations
2. Sphingosine 1 phosphate rec modulators (-imod)
3. monoclonal antibodies/ chemotherapy drugs (2nd/3rd line unless agressive)
141
What is the preferred agent for MS in pregnancy?
1. Glatiramer acetate (Copaxone)
2. Interferon beta products
142
What is the MOA with Glatiramer acetate for MS?
immune modulator, induces and activates T-lymphocyte suppressor cells in prelapsing forms of MS
143
What are warnings with Glatiramer acetate?
1. Chest pain
2. immediate-post inj rxn
3. lipoatrophy
144
What are SEs with Glatiramer acetate?
1. Inj site rxn (inflammation, erythema, pain, residual mass)
2. Flushing
3. Diaphoresis
4. Dyspnea
5. infection
6. pain
7. weakness
8. rash
9. anxiety
10. nausea
11. nasopharyngitis
12. vasodialation
13. nasopharingitis
145
How is Glatiramer acetate dosed/administered/stored?
1. 20mg SQ QD
2. 40mg SQ three times weekly (at least 48h apart)
3. Check solution for discoloration, discard if present
4. Can be kept at room temperature for up to 1 month or in the refrigerator (preferred)
5. If cold, let stand at room temp for 20 min prior to inj
6. SQ: Abdomen/love handles/thighs/ upper arm
146
Glatiramer acetate
Copaxone
Glatopa
147
What is the MOA of interferon beta products for MS?
alter the expression and response to surface antigens, enhancing immune cell function
148
What are warnings with interferon beta products?
1. Psychiatric events (depression/suicide)
2. Inj site Necrosis
3. Elevated LFTs
4. Thyroid dysfxn (hyper/hypo)
5. myelosupression
6. infections
7. anaphylaxis
8. worsening of CV disease
9. seizure risk
10. formulations containing albumin can increase risk of Creutzfeldt-Jakob disease transmission; avoid in a;bumin sensitive patients
149
What are SEs with interferon beta products?
1. Flu like sx following administration lasting min-h: decreases with cont tx-can use tylenol/NSAIDs/start with low doses and titrate
2. Visual disturbances
3. fatigue
4. depression
5. pain
6. UTI
7. headache
150
What is monitored with interferon beta products?
1. LFTs
2. CBC (month 1, 3, 6, then periodically)
3. thyroid fxn every 6 months (as clinically necessary)
151
How are interferon beta products stored/administered?
1. Refrigerate (EXCEPT BETASERON/EXTAVIA; may be stored at room temperature)
2. Let stand at room temperature prior to injection
3. Do not expel air bubble in prefilled syringes due to loss of dose
4. DO NOT SHAKE: Avonex, Betaseron, Extavia
5. Use Betaseron and Extavia within 3h of reconstitution
152
Interferon beta-1a
Avonex
Avonex Pen
Rebif
Rebif Rebidose
153
Interferon beta-1b
Betaseron
Extivia
154
Peginterferon beta-1a
Plegridy
Plegridy Starter Pack
155
How often is interferon beta-1a dosed?
Avonex: IM weekly
Refib: SQ 3x weekly (at least 48h apart)
156
How often is interferon beta-1b dosed?
SQ every other day (use within 3h of reconstitution)
157
How often is peginterferon beta-1a dosed?
SQ on day 1, 15, then Every 14 days after day 29
158
What is the MOA of Sphingosine 1-phosphate (S1P) rec modulator for MS (-imod)?
block lymphocytes from exiting the lymph nodes, reducing lymphocytes in the periphery, may limit lymphocyte migration to the CNS
159
What are CIs to using S1P modulators (-imod)?
1. some arrhythmias
2. any of the following in the past 6mo: MI, unstable angina, stroke/TIA, or some HF (decompensated req. hospitalization/ Class III/IV
3. Use on an MAOi or untreated sleep apnea (Ozanimod)
4. CYP2C9*3/*3 genotype testing required before use (Siponimod)
160
What are warnings with S1P modulators (-imod)?
1. Bradycardia/bradyarrhythmia- caution wit other drugs that slow HR
2. Monitor pts on fingolimod for at least 6h after the first dose (ECG at baseline and end of observation period or if tx interruption)
3. Increased risk of inf (monitor CBC)
4. Screen for VZV antibodies before starting: vaccinate if negative or no history of chicken pox
5. Macular edema (monitor with eye exams)
6. Hepatotoxicity (monitor LFTs)
7. malignancies
8. fetal risk (use contraception during and for some time after stopping therapy if childbearing potential; duration 7-90 days depending on the drug)
9. high BP
10. decreased lung function
11. MS can become much worse if stopped
161
How is Mayzent (siponimod) stored/administered?
Unopened Mayzent is stored in the refrigerator, once opened it can be stored at room temperature
162
Fingolimod
Gilenya
Tascenso ODT
163
Ozanimod
Zeposia
164
Ponesimod
Ponvory
165
Siponimod
Mayzent
166
What is the MOA of Fumarates or Nuclear Factor (erythroid-derived-2)-like 2 (Nrf2) activators for MS?
anti-inflammatory and cytoprotective
167
What are SEs/warnings with Fumarates or Nuclear Factor (erythroid-derived-2)-like 2 (Nrf2) activators for MS?
1. Hepatotoxicity (monitor LFTs)
2. neutopenia (reversible, monitor CBC)
3. PML
4. Flushing (prevention with aspirin 30 minutes prior to dose and administer with food)
5. GI side effects (less with Vumerity)
6. Do not crush/chew/sprinkle contents on food
168
Dimethyl fumarate
Tecfidera
169
Diroximel fumarate
Vumerity
170
Monomethyl fumarate
Bafiertam
Active metabolite of diroximel/dimethyl fumarate
171
What is the MOA of teriflunomide?
Pyrimidine synthesis inhibitor: may reduce the number of activated lymphocytes in the CNS
172
What are warnings/SEs with teriflunomide?
1. Severe hepatotoxicity/ teratogenicity
2. CI in pregnancy
3. May use accelerated elimination if pregnancy desired
4. Active metabolite of leflunomide
173
Teriflunomide
Aubagio
174
What CD20-directed monoclonal antibodies are used for MS?
1. Ofatumumab (Kesimpta)
2. Ublituximab-xiiy (Briumvi)
3. Ocrelizumab (Ocrevus)
175
What are CIs to using CD20-directed monoclonal antibodies for MS?
Active Hep B infection, screen before starting therapy
176
What are warnings with CD20-directed monoclonal antibodies for MS?
1. Increased risk of serious/fatal infections (PML)
2. Avoid live vaccines during tx
3. Fetal risk
4. infusion rxn
5. reduction in immunoglobulin levels
6. immune mediated colitis (Ocrevus)
177
How are CD20-directed monoclonal antibodies for MS dosed?
1. Briumi and Ocrevus: Premedicate with a steroid, antihistamine, and/or tylenol (indicated for relapsing forms of MS)
2. Requires a 0.22 micron in-line filter (similar safety issues to rituximab)
178
Ofatumumab
Kesimpta (SQ inj)
Arzerra (for CLL)
179
Ublituximab-xiiy
Briumvi (IV)
180
Ocrelizumab
Ocrevus (IV)
181
What is the MOA of alemtuzumab?
CD52-directed cytolytic monoclonal antibody
182
What are BBWs with alemtuzumab?
REMS program required; serious/fatal autoimmune conditions, infusion rxn, malignancy, stroke
183
What are CIs with alemtuzumab?
HIV (causes prolonged decrease in CD4)
184
What are indications/precautions with alemtuzumab for MS?
1. Indicated when inadequate response to ≥2 MS drugs
2. Complete all vaccines 6 weeks before starting
3. Premedicate with steroid, antihistamine and/or tylenol
185
Alemtuzumab
Lemtrada (IV)
Campath (for CLL)
186
What is the MOA of natalizumab for MS?
monoclonal antibody that binds to the alpha-4 subunit on integrin molecules
187
What are BBWs with natalizumab?
Progressive Multifocal Leukoencephalopathy: only available through REMS TOUCH prescribing program
188
Natalizumab
Tysarbi (IV); also used for chron's
189
What is the MOA of cladribine?
Oral anti-neoplastic
190
What are warnings/SEs/CIs with cladribine?
1. BBW: malignancy and teratogenicity
2. CI with current malignancy, HIV, active chronic infection
3. Contracetion MUST be used for males and females for 6 mo after the last dose
191
Cladribine
Mavenclad
192
What is the MOA of dalfampridine for MS?
K channel blocker, may increase nerve signal transduction and improve walking speed
193
What are warnings/SEs/CIs with dalfampridine?
1. CI with history of seizures
2. Not disease modifying
3. Takes up to 6 weeks to show efficacy, most patients do not respond
194
Dalfampridine
Ampyra
195
What agents can be used for symptomatic care with MS?
1. Anticholinergics for incontinence
2. laxatives for constipation/loperamide for diarrhea
3. Muscle relaxants/analgesics for pain (botulinum toxin; Botox)
4. Propranolol for tremor
5. Dalfampridine for walking speed
6. SNRI for neuropathic pain
7. Modafinil/stimulants for fatigue
8. Meclizine/scopalamine for dizziness/vertigo
9. Acetylcholinesterase inhibitors (donepezil) for cognition
10. phosphodiesterase-5 inhibitors for ED
*** May worsen other symptoms, use caution (anticholinergics can worsen cognition)
196
What is Raynaud's Phenomenon?
cold/stress leads to vasospasm in the extremities (fingers/toes), less blood flow causes the skin to turn white/blue
197
What drugs can cause/worsen Raynaud's?
1. Stimulants (including pseudoephedrine/illicit durgs)
2. Beta-blockers
3. Bleomycin/Cisplatin
198
How is Raynaud's managed?
Nifedipine ER; vasodialation
199
What ingredients may contain gluten?
1. Wheat, barley, rye
2. Corn/potato/tapioca/wheat starch
200
What are s/sx of myasthenia gravis?
Antibodies attack connections between nerves and muscles (usually Ach receptors):
1. Vision changes (double vision- diplopia, drooping eyelids- ptosis)
2. difficulty chewing/swallowing
3. jaw/neck weakness
201
What drugs can worsen myasthenia gravis?
1. Some ABX (aminoglycosides, quinolones, macrolides)
2. Magnesium salts
3. Some antiarrhythmics
4. Beta-blockers/ CCBs
5. Some antipsychotics
6. Muscle relaxants
7. Botulinum toxin (Botox)
202
What is the 1st line/mainstay treatment for myasthenia gravis?
Pyridostigmine (Mestinon)
203
What is the MOA of Pyridostigmine for myasthenia gravis?
Cholinesterase inhibitor; blocks the breakdown of acetylcholine by acetylcholinesterase, which improves neuromuscular transmission and increases muscle strength
204
What are CIs with pyridostigmine?
Mechanical intestinal or urinary obstruction
205
What are the warnings/SEs with pyridostigmine?
1. Cholinergic effects: symptoms of excess Ach can occur (salivation, lacrimation, excessive urination, diarrhea)
2. CVD
3. Glaucoma
4. Bronchospastic respiratory disease (COPD/asthma)
206
How is pyridostigmine dosed?
Myasthenia Gravis: usually 600mg/day PO divided in 5-6 doses
IV/IM: myasthenia gravis crisis, nerve gas exposure, reversal of nondepolarizing muscle relaxants
207
What other treatments are used for myasthenia gravis?
1. Immunotherapy (steroids, azathiopurine, cyclosporine, MTX) + pyridostigmine
2. removal of thymus gland
3. plasmapheresis/ IVIG
208
What treatment is used for treatment in adults with myestenia gravis who are ACH receptor antibody positive?
Ecluzumab (Soliris) inj complement inhibitor
209
What are OTC opthalmic options for dry eye (xeropthalmia) due to Sjögren's Syndrome?
Artificial Tears:
1. Systane
2. Refresh
3. Clear Eyes
4. Liquifilm
***If irritating, use preservative-free (Benzalkonium Chloride preservative can irritate)
210
What are Rx opthlmic options available for dry eye due to Sjögren's Syndrome?
1. Cyclosporine emulsion (Restasis)
2. Lifitegrast (Xiidra)
211
What are SEs with cyclosporine eye drops?
Ocular:
1. burning/stinging/itching/pain
2. reddness
3. blurred vision
4. discharge
5. foreign body sensation
6. 3-6 mo to increase tear production
212
What should patients be counseled on before using Restasis?
Prior to use, invert the vial several times to make the emulsion uniform
213
Cyclosporine Emulsion
Restasis
Cequa
Verkazia
214
What are SEs with Xiidra eye drop?
Unusual taste
eye irritation/discomfort/blurred vision
215
How should Lifetegrast be stored?
In the original foil pouch to protect from light
216
Lifetegrast
Xiidra
217
What are OTC options for dry mouth (xerostomia) due to Sjögren's Syndrome?
1. Xylitol containing SF gum/lozenges
2. Rinses with antimicrobial mouthwash (Aquoral, Mouth Kote, Biotene Oral Balance)
3. carboxymethylcellulose/glycerin containing mouth wash
218
What are RX options for dry mouth (xerostomia) due to Sjögren's Syndrome?
PO Muscarinic agonists:
Pilocarpine (Salagen)
Cevimeline (Evoxac)
219
What are CIs to using PO Muscarinic agonists?
1. Asthma
2. Narrow Angle glaucoma
220
What is non-drug treatment for plaque psoriasis?
1. UV light causes activated T cells to die
2. UVB phototherapy (mild-moderate)
3. laser light therapy
221
What are topical options for treating psoriasis?
1. Steroids
2. Calcipotriene- Vit D analog
3. anathralin
4. Retinoids
5. Salisylic acid (shampoo usually)
6. tapinarof
7. coal tar
8. Calcineurin inhibitors (Protopic, Elidel)
222
What is the preferred agent for topical treatment of psoriasis on the face?
Calcineurin inhibitors (protopic, Elidel)
223
What are counseling points about topical steroids for psoriasis?
1. Only use short-term
2. Can be used as monotherapy or with other therapies
224
What are counseling points about coal tar for psoriasis?
1. Messy, time-consuming, and stain
2. Skin irritation/ photosensitivity
3. Available as a cream, foam, emulsion, ointment, oil, shampoo, and bar soap
4. Avalible in combination with salicylic acid OTC
5. Avalible OTC
225
What are counseling points about salicylic acid for psoriasis?
Do not use with other salycilates, systemic absorption can occur
226
What are other uses for coal tar?
1. Dandruff
2. Dermatits
227
Coal Tar
DHS Tar
Ionil-T
Psoriasin
Pentrax Gold
228
Coal Tar + salicylic acid
Tarsum
229
Tazarotene
Tazorac
(topical retinoid)
230
Tazarotene + halobetasol (steroid)
Duobril
231
What is the MOA of anathralin?
Keratolytic containing salicylic acid with irritant potential, increased contact time as tolerated up to 30 min
232
Anthralin
Zithranol
233
What are counseling points with calcipotriene (Vit D analog)?
1. CI in Ca/Vit D toxicity
2. If using a suspension, shake well
3. Do not apply to face, axillae, groin
234
Calcipotriene
Dovonex
Sorilux
235
Calcipotriene + betamethasone
Taclonex ointment
Enstilar foam
236
What couseling points with tapinarof?
1. folliculitis
2. nasopharyngitis
3. contact dermatitis
4. pruritis
5. wash hands after use
237
Tapinarof
VTAMA
238
What are systemic treatments for psoriasis?
1. Immunosuppressants: MTX, cyclosporine, hydroxyurea
2. Immunomodulators: entanercept, infliximab, adalimumab, certolizumab
3. IL receptor antgonists; mab (SQ)
4. phosphodiesterase-4 inhibitor
5. selective tyrosine kinase 2 inhibitor
6. Acitrenin (retinoid)
239
What are warnings with acitrentin (systemic retinoid)?
1. BBW: hepatotoxicity and pregnancy (female must sign informed consent before dispensing)
2. Used only in severe cases when unresponsive to other therapies due to CI/SE
240
What are warnings/SEs with apremilast?
Warnings: Weight loss, depression/suicidal ideation
SEs: Diarrhea, N/V, headache
241
Apremilast
Otezla (phosphodiesterase 4 inhibitor)
242
What are SEs with IL receptor antagonist mabs for psoriasis?
1. Serious infections; screen for latent TB and give live vaccines
2. Diarrhea
3. URTIs
4. BBW suicidal ideation/behavior: REMS program required
5. May exacerbate chron's/ latex HSR
243
Brodalumab
Siliq
244
Bimekizumab
Bimzelx
245
Guselkumab
Tremfya
246
Ixekizumab
Taltz
247
Risankizumab
Skyrizi
248
Secukinumab
Cosentyx
249
Tildrakizumab
Ilumya
250
Ustekinumab
Stelera
251
What are warnings/SEs with deucravacitnib (Sotyktu)?
Warnings: may increase risk of inf, screen for latent TB, avoid vaccines, malignancy, Rhabdomyolysis, lab abnormalities (Elevated TGs and LFTs), Do not use with other immunesuppressants
SEs: URTIs, elevated CPK, mouth ulcers, acne
252
Deucravacitnib
Sotyktu
FDA approved severe plaque psoriasis
Selective tyrosine kinase 2 inhibitor
