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Fall 2024 > Therapeutics Exam 4 Lupus > Flashcards

Therapeutics Exam 4 Lupus Flashcards

1
Q

What are the 3 buckets of lupus etiology?

A

Genetics
Hormonal (estrogen)
Environmental

*exact etiology is unknown

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2
Q

What drugs cause Drug-Induced Lupus Erythematous?

A

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

(My Pretty Malar Marking Probably Has A TransIent Quality)

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3
Q

What are the symptoms of lupus?

A

Fatigue
Depression
Photosensitivity*
Joint Pain
N/V
Fever
Weight Loss
Malar “Butterfly” Rash*

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4
Q

What is a classic skin manifestation of lupus?
A. butterfly-shaped rash on the face
B. blisters on the hand
C. scaling on the scalp
D. darkening around the eyes

A

A. butterfly-shaped rash on the face

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5
Q

Which of the following is a common trigger for lupus flare-ups?
A. regular exercise
B. high sodium intake
C. sun exposure
D. high cholesterol

A

C. sun exposure

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6
Q

What are the 2 diagnostic tools for lupus?

A

SLICC (Systemic Lupus International Collaborating Clinics)

EULAR/ACR (European League Against Rheumatism/ American College of Rheumatology 2019)

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7
Q

Using the SLICC guidelines, what is required for a patient to be diagnosed with lupus?

A

They meet >/= 4 total features with 1 from each group

OR

Biopsy-proven Lupus nephritis WITH systemic lupus
(+ anti-dsDNA antibodies or + ANA)

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8
Q

Using the EULAR/ACR guidelines, what is required for a patient to be diagnosed with lupus?

A

*Only count the highest-weighted criterion score within a single domain

Lupus when: Patient’s score is >/= 10 AND at least 1 clinical criterion is fulfilled

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9
Q

What are the 4 laboratory tests done to determine a diagnosis of lupus?

A

Anti-Nuclear Antibody (ANA)

Anti-Double-Stranded DNA (anti-dsDNA)

Anti-Smith Antibody (Anti-SM)

Antiphospholipid Antibody

**all positive in lupus and negative when healthy

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10
Q

What is the reference range of Anti-Nuclear Antibody (ANA)?

A

> 1:40 = positive

*note that this is not specific

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11
Q

What does the Anti-Double-Stranded DNA lab value tell us?

A

-High specificity

-Correlates with disease activity

-Important marker in lupus nephritis

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12
Q

What does the Anti-Smith Antibody (Anti-SM) lab value tell us?

A

-High specificity

-Binds to SM proteins that are attached to DNA

-Found in smaller % of patients

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13
Q

What does the Antiphospholipid Antibody lab value tell us?

A

There are increased clotting factors and a higher clot risk when this is positive

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14
Q

What are the 5 drugs/classes that a patient with lupus will be on?

A

Hydroxychloroquine
NSAIDs
Glucocorticoids
Immunosuppressants
Biologics

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15
Q

What is the moa of hydroxychloroquine?

A

Antimalarial
-inhibits overactive immune cells

-reduces flares and helps manage pain

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16
Q

Who should receive hydroxychloroquine?

A

All patients with lupus

1st-line

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17
Q

What is the dosing of hydroxychloroquine?

A

200-400mg po daily

MAX: 400 mg daily

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18
Q

What are the side effects of hydroxychloroquine?

A

Retinal toxicity (bulls eye maculopathy)

Psychiatric events

QTc prolongation + cardiomyopathy

Hypersensitivity

Hypoglycemia

**Hemolytic anemia (G6PD deficiency)

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19
Q

How does a G6PD deficiency effect patients receiving hydroxychloroquine?

A

This is an x-linked disorder that causes RBCs to break down prematurely

-Increases risk of anemia with hydroxychloroquine

-Do not give this drug to pts with this mutation

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20
Q

What is the role of NSAIDs in lupus?

A

1st-line for mild symptoms

-Antipyretic
-Anti-inflammatory
-Analgesic

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21
Q

What is the dosing of NSAIDs used for lupus?

A

Ibuprofen: 400-600 mg po q6-8h

Naproxen: 500 mg po bid

22
Q

What is the role of glucocorticoids in lupus patients?

A

Inhibit B and T cell responses

-Anti-inflammatory, helpful during flares

*Adjunct treatment, if not responsive to NSAIDs/hydroxychloroquine

23
Q

What are the glucocorticoids that we can use for lupus?

A

Prednisone
Methylprednisolone
Topical

24
Q

What is the dosing of the glucocorticoids?

A

Mild/Mod Prednisone: 5-30 mg/day po

Severe Prednisone: 1mg/kg/day po

IV methylprednisolone: 500-1000 mg IV daily x 3-6 days, then po prednisone

25
Q

What are the topical glucocorticoids that can be used?

A

Low-potency (face): Fluocinolone valerate + Hydrocortisone butyrate

Moderate (trunk + extremities): Triamcinolone acetonide + Betamethasone valerate

High potency (scalp sores + palms): Clobetasol

26
Q

What is the role of immunosuppressants in lupus therapy?

A

Adjunct to steroid therapy to lower steroid dosing

Insufficient response to hydroxychloroquine

27
Q

What are the immunosuppressants used for lupus?

A

Methotrexate
Azathioprine
Cyclophosphamide
Mycophenolate mofetil

28
Q

What is the dosing of methotrexate?

A

5-15mg WEEKLY

29
Q

What are the side effects of methotrexate?

A

Bone marrow suppression
Infection

**this is the only immunosuppressant that does not cause malignancy

30
Q

What is the dosing of mycophenolate?

A

1-1.5mg BID

31
Q

What are the side effects if mycophenolate?

A

Bone marrow suppression
Infection
malignancy
AIS

32
Q

What is the dosing of cyclophosphamide

A

1-1.5 mg/kg once daily

IV: 0.5 mg/m2 BSA q month x 6 months

**this is the only drug in this class with IV dosing

33
Q

What is the dosing of Azathioprine?

A

50 mg daily

34
Q

What are the side effects of cyclophosphamide and azathioprine?

A

Bone marrow suppression
Infection
Malignancy

35
Q

What deficiency needs to be monitored with azathioprine?

A

TPMT deficiency

36
Q

How does TPMT deficiency affect azathioprine?

A

Azathioprine is a prodrug metabolized to 6-MP

6-MP can go down two pathways, one where it becomes active metabolites and one where it becomes inactive

TPMT is responsible for producing inactive metabolites from 6-MP

When a patient is TPMT deficient, all of the 6-MP is activated making the activity of the drug be way too high

-toxic bone marrow suppression

CANNOT GIVE AZATHIOPRINE TO THESE PATIENTS

37
Q

What is the role of biologics in lupus therapy?

A

Used when inadequate response to hydroxychloroquine and immunosuppressants

38
Q

What are the biologics used in lupus?

A

Belimumab
Rituximab
Anifrolumab

39
Q

What are the important points to remember with biologics?

A

No live vaccines 30 days before starting therapy or during therapy

Do not use more than 1 biologic at a time

40
Q

What is the dosing of Belimumab?

A

10mg/kg every 2 weeks
-give 3 doses

41
Q

What is the dosing of Anifrolumab?

A

300 mg every 4 weeks

42
Q

When giving rituximab, what is an important point to remember?

A

Patients must be pre-medicated for infusion reactions 30 minutes before the IV infusion

43
Q

What must patients be screened for before starting rituximab?

A

Hepatitis B

44
Q

For cutaneous lupus what are our 1st line treatment options?

A

Topical Glucocorticoid Agents:
Clobetasol
Betamethasone
Triamcinolone
Hydrocortisone

45
Q

What is the treatment for lupus nephritis?

A

Mild/Mod: Glucocorticoid +/- Immunosuppressant

Severe: Mycophenolate mofetil is the preferred immunosuppressant

Consider triple therapy

46
Q

What drug should not be given to patients with nephritis?

A

NSAIDs

47
Q

Pregnant patients with lupus have the best prognosis when they achieve remission for how many months before pregnancy?

A

> /= 6 months

48
Q

What drugs for lupus can be used in pregnancy?

A

Hydroxychloroquine -1st choice

NSAIDs (until wk 20)

Glucocorticoids -lowest dose for shortest time

49
Q

What is antiphospholipid syndrome?

A

An autoimmune disorder than can cause blood clots and miscarriages

50
Q

For patients with the antiphospholipid antibody, what do we give as prophylaxis?

A

No prior fetal loss: Aspirin 81mg

Recurrent fetal loss: Aspirin 81mg +/- LMWH

51
Q

For patients with antiphospholipid antibody, what do we give as therapy for acute thrombotic events/ hx of thrombosis?

A

LMWH

Fall 2024 (16 decks)

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