Therapeutics Exam 4 Lupus Flashcards
What are the 3 buckets of lupus etiology?
Genetics
Hormonal (estrogen)
Environmental
*exact etiology is unknown
What drugs cause Drug-Induced Lupus Erythematous?
Methimazole
Propylthiouracil
Methyldopa
Minocycline
Procainamide
Hydralazine
Anti-TNF agents
Terbinafine
Isoniazid
Quinidine
(My Pretty Malar Marking Probably Has A TransIent Quality)
What are the symptoms of lupus?
Fatigue
Depression
Photosensitivity*
Joint Pain
N/V
Fever
Weight Loss
Malar “Butterfly” Rash*
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. butterfly-shaped rash on the face
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
C. sun exposure
What are the 2 diagnostic tools for lupus?
SLICC (Systemic Lupus International Collaborating Clinics)
EULAR/ACR (European League Against Rheumatism/ American College of Rheumatology 2019)
Using the SLICC guidelines, what is required for a patient to be diagnosed with lupus?
They meet >/= 4 total features with 1 from each group
OR
Biopsy-proven Lupus nephritis WITH systemic lupus
(+ anti-dsDNA antibodies or + ANA)
Using the EULAR/ACR guidelines, what is required for a patient to be diagnosed with lupus?
*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
What are the 4 laboratory tests done to determine a diagnosis of lupus?
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
What is the reference range of Anti-Nuclear Antibody (ANA)?
> 1:40 = positive
*note that this is not specific
What does the Anti-Double-Stranded DNA lab value tell us?
-High specificity
-Correlates with disease activity
-Important marker in lupus nephritis
What does the Anti-Smith Antibody (Anti-SM) lab value tell us?
-High specificity
-Binds to SM proteins that are attached to DNA
-Found in smaller % of patients
What does the Antiphospholipid Antibody lab value tell us?
There are increased clotting factors and a higher clot risk when this is positive
What are the 5 drugs/classes that a patient with lupus will be on?
Hydroxychloroquine
NSAIDs
Glucocorticoids
Immunosuppressants
Biologics
What is the moa of hydroxychloroquine?
Antimalarial
-inhibits overactive immune cells
-reduces flares and helps manage pain
Who should receive hydroxychloroquine?
All patients with lupus
1st-line
What is the dosing of hydroxychloroquine?
200-400mg po daily
MAX: 400 mg daily
What are the side effects of hydroxychloroquine?
Retinal toxicity (bulls eye maculopathy)
Psychiatric events
QTc prolongation + cardiomyopathy
Hypersensitivity
Hypoglycemia
**Hemolytic anemia (G6PD deficiency)
How does a G6PD deficiency effect patients receiving hydroxychloroquine?
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
What is the role of NSAIDs in lupus?
1st-line for mild symptoms
-Antipyretic
-Anti-inflammatory
-Analgesic
What is the dosing of NSAIDs used for lupus?
Ibuprofen: 400-600 mg po q6-8h
Naproxen: 500 mg po bid
What is the role of glucocorticoids in lupus patients?
Inhibit B and T cell responses
-Anti-inflammatory, helpful during flares
*Adjunct treatment, if not responsive to NSAIDs/hydroxychloroquine
What are the glucocorticoids that we can use for lupus?
Prednisone
Methylprednisolone
Topical
What is the dosing of the glucocorticoids?
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
What are the topical glucocorticoids that can be used?
Low-potency (face): Fluocinolone valerate + Hydrocortisone butyrate
Moderate (trunk + extremities): Triamcinolone acetonide + Betamethasone valerate
High potency (scalp sores + palms): Clobetasol
What is the role of immunosuppressants in lupus therapy?
Adjunct to steroid therapy to lower steroid dosing
Insufficient response to hydroxychloroquine
What are the immunosuppressants used for lupus?
Methotrexate
Azathioprine
Cyclophosphamide
Mycophenolate mofetil
What is the dosing of methotrexate?
5-15mg WEEKLY
What are the side effects of methotrexate?
Bone marrow suppression
Infection
**this is the only immunosuppressant that does not cause malignancy
What is the dosing of mycophenolate?
1-1.5mg BID
What are the side effects if mycophenolate?
Bone marrow suppression
Infection
malignancy
AIS
What is the dosing of cyclophosphamide
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
What is the dosing of Azathioprine?
50 mg daily
What are the side effects of cyclophosphamide and azathioprine?
Bone marrow suppression
Infection
Malignancy
What deficiency needs to be monitored with azathioprine?
TPMT deficiency
How does TPMT deficiency affect azathioprine?
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
What is the role of biologics in lupus therapy?
Used when inadequate response to hydroxychloroquine and immunosuppressants
What are the biologics used in lupus?
Belimumab
Rituximab
Anifrolumab
What are the important points to remember with biologics?
No live vaccines 30 days before starting therapy or during therapy
Do not use more than 1 biologic at a time
What is the dosing of Belimumab?
10mg/kg every 2 weeks
-give 3 doses
What is the dosing of Anifrolumab?
300 mg every 4 weeks
When giving rituximab, what is an important point to remember?
Patients must be pre-medicated for infusion reactions 30 minutes before the IV infusion
What must patients be screened for before starting rituximab?
Hepatitis B
For cutaneous lupus what are our 1st line treatment options?
Topical Glucocorticoid Agents:
Clobetasol
Betamethasone
Triamcinolone
Hydrocortisone
What is the treatment for lupus nephritis?
Mild/Mod: Glucocorticoid +/- Immunosuppressant
Severe: Mycophenolate mofetil is the preferred immunosuppressant
Consider triple therapy
What drug should not be given to patients with nephritis?
NSAIDs
Pregnant patients with lupus have the best prognosis when they achieve remission for how many months before pregnancy?
> /= 6 months
What drugs for lupus can be used in pregnancy?
Hydroxychloroquine -1st choice
NSAIDs (until wk 20)
Glucocorticoids -lowest dose for shortest time
What is antiphospholipid syndrome?
An autoimmune disorder than can cause blood clots and miscarriages
For patients with the antiphospholipid antibody, what do we give as prophylaxis?
No prior fetal loss: Aspirin 81mg
Recurrent fetal loss: Aspirin 81mg +/- LMWH
For patients with antiphospholipid antibody, what do we give as therapy for acute thrombotic events/ hx of thrombosis?
LMWH
