29. Autoimmune Conditions Flashcards Preview

Pharmacy > 29. Autoimmune Conditions > Flashcards

Flashcards in 29. Autoimmune Conditions Deck (57):
1

Susan is a 78 year-old female patient with Sjogren's syndrome. Susan has considerable difficulty with dry eyes, and dry mouth. She asks the pharmacist for advice on helping her manage the dry mouth. Which of of the following statements concerning dry mouth are correct? (Select ALL that apply.)

A. Biotene Gel and Mouth Kote are saliva substitutes that may be helpful.
B. If using sugar free-gum, sorbitol can help prevent cavities but xylitol might cause diarrhea.
C. Pilocarpine in the oral form (Salagen) or cevimeline (Exovac) will increase salivation; they are, however, pricey and can cause urination and sweating.
D. Try to avoid anticholinergic agents in anyone who has glaucoma that is not well-controlled; they may worsen the condition.
E. A major complication of dry mouth is tooth decay.
 

A, C, D, E. If using sugar free-gum, sorbitol can cause diarrhea and possible cramping, particular in IBS patients or anyone with difficulty taking sorbitol. Xylitol may be useful in chewing gum for cavity prevention. For dry mouth always use sugar-free candy or gum. A major complication of dry mouth is tooth decay (dental caries, or cavities).

Sjogren's Syndrome

Autoimmune disease most often characterized by severe dry eyes and dry mouth.

Dry eyes: use artificial teardrops (1st line) available OTC. Cyclosporine eye drops (Restasis) can be used in patients who do not get satisfactory relief from other methods. Restasis is an emulsion applied twice daily (remove contact lenses before use) and separate from artificial tears by 15 minutes.

Dry mouth: Cholinergic drugs would produce saliva. Pilocarpine (Salagen) dosed 4x/day. Cevimeline (Evoxac) dosed TID. CI for both drugs: uncontrolled asthma, narrow-angle glaucoma

2

Etanercept carries the following health risks, which must be conveyed to the patient: (Select ALL that apply.)

A. Teratogenicity
B. Liver damage
C. Exacerbation of heart failure
D. Risk of infection
E. Reactivation of latent TB
 

B, C, D, E. For liver monitoring, instruct the patient to call the doctor right away if they have any of these symptoms: feeling very tired, skin or eyes look yellow, poor appetite or vomiting, or pain on the right side of the stomach. Instruct patients that this medicine may worsen congestive heart failure (CHF). They must notify the doctor right away if they experience a sudden weight gain or shortness of breath.

etanercept (Enbrel) – Anti-TNF, 50mg SC weekly

Warnings: serious infections and malignancies (remember LIST)

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)

No live vaccines

Antibody induction: may develop antibodies against these agents which reduces efficacy

Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)

Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs

3

Charles is a 40 year-old patient who has had "stomach issues" for many years, including pain after eating. He has been self-treating for many years by avoiding foods he knows will cause bad symptoms, including bread. Recently, he saw a gastroenterologist who diagnosed celiac disease and recommended avoiding all gluten intake, including in even very small amounts. Charles is a regular at your pharmacy. He has come in to pick up his medications and asks to speak to the pharmacist. He tells the pharmacist he cannot take any pills that contain gluten. What key words will the pharmacist search for in the package insert in order to check if gluten is present in the excipients?

A. Starch, or wheat
B. Starch, or corn
C. Starch, or potato
D. Starch, or rice
E. Starch, or flax seed
 

A. The pharmacist is checking for wheat. If the word starch is used, it could be wheat. If starch is listed without specifying the type, the manufacturer should be contacted. They may or may not verify the ingredients used as excipients because they may not wish to take responsibility for bulk products they purchase. In the celiac chapter of the RxPrep text resources are listed which could be used to attempt to verify content.

Celiac Disease

Gluten found in barley, wheat, and rye. Triggers an immune response in the small intestine and chronic inflammation leads to damage of the small intestine's lining and prevents absorption of some nutrients.

Drugs are gluten-free, excipients may not be.

4

Improper administration of Restasis can lead to infections, some of which have caused sight loss. Which of the following statement/s concerning Restasis is correct? (Select ALL that apply.)

A. The correct dose is one drop twice daily, approximately twelve hours apart.
B. One vial should be used each time, and immediately discarded after each use. Do not keep any leftover medication.
C. It could take 3 to 6 months after beginning therapy to notice an increase in tear production.
D. The most common side effect is a temporary burning sensation.
E. The active ingredient is pilocarpine.
 

A, B, C, D. The most common side effect is a temporary burning sensation, although many patients find the drop soothing since the eye is very dry and it is a liquid. Other side effects include eye redness, discharge, watery eyes, eye pain and/or a foreign body sensation. Most patients notice an increase in tear production in about a month (if it works) but some take much longer to see a benefit.

Dry eyes: use artificial teardrops (1st line) available OTC. Cyclosporine eye drops (Restasis) can be used in patients who do not get satisfactory relief from other methods. Restasis is an emulsion applied twice daily (remove contact lenses before use) and separate from artificial tears by 15 minutes.

5

A patient using methotrexate for rheumatoid arthritis should receive the following instructions from the pharmacist concerning the dosing schedule:

A. This medication is taken weekly.
B. This medication is taken daily.
C. This medication is taken monthly.
D. This medication is used only when you have an acute flare.
E. If you experience an acute flare, double the daily dose.
 

A.

In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.

methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD

Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose

SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, alopecia (using auto-injector can bypass GI problems)

CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)

Folic acid supplementation on the day after MTX

6

CY is a rheumatoid arthritis patient that states she had a hypersensitivity reaction to etanercept. What drug class does etanercept belong?

A. Anti-CD 20
B. Folate antagonist
C. Interferon inhibitor
D. Interleukin inhibitor
E. Tumor necrosis factor inhibitor
 

E. Etanercept is a TNF inhibitor.

Biologic DMARDs

2 categories: TNF and non-TNF

Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line

Non-TNF inhibitors: 2nd line

Warnings: serious infections and malignancies (remember LIST)

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)

No live vaccines

Antibody induction: may develop antibodies against these agents which reduces efficacy

Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)

Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs

 

Anti-TNF

etanercept (Enbrel) – Anti-TNF, 50mg SC weekly

adalimumab (Humira): 40mg SC every other week, or weekly when without MTX

infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions

certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks

golimumab (Simponi): 50mg SC monthly, IV requires filter

7

HR is a 44 y/o female who comes to the clinic with complaints of a red rash over the bridge of her nose. The rash is not painful and it is not pruritic. She has been taking the following medications for the past 2 years: omeprazole, aspirin, hydrochlorothiazide, hydralazine, atorvastatin, and sertraline. Which of HR's medications is most likely causing her rash?

A. Aspirin
B. Hydrochlorothiazide
C. Hydralazine
D. Atorvastatin
E. Sertraline
 

C. Hydralazine can cause drug-induced systemic lupus erythematosus (SLE).

Systemic Lupus Erythematosus (SLE)

Female, 15-45 years, African American

Butterfly rash (not painful), photosensitivity, joint pain, fatigue, weight loss

Lupus nephritis, hematologic and neurologic problems

Drug-induced Lupus Erythematosus (DILE): procainamide is most common drug that causes this, hydralazine (alone and in BiDil)

8

What is the mechanism of action of Raynaud’s Phenomenon? 

A. Inflammation
B. Vasospasm
C. Hypotension
D. Angina
E. Migraines
 

B. Raynaud’s is triggered by exposure to cold and/or emotional stress, which causes vasospasm in the extremities.

Raynaud's

Cold or stress can trigger vasospasm of small blood vessels. Skin turns white then to blue fingers and toes. When warmed, painful swelling can occur in hands and feet.

Drug of choice are calcium channel blockers. Nifedipine is commonly used for prevention.

9

Celiac disease (celiac sprue) is an immune response to gluten. Which of the following contain gluten? (Select ALL that apply.)

A. Wheat
B. Barley
C. Oats
D. Rye
E. Rice
 

A, B, D.

Celiac Disease

Gluten found in barley, wheat, and rye. Triggers an immune response in the small intestine and chronic inflammation leads to damage of the small intestine's lining and prevents absorption of some nutrients.

Drugs are gluten-free, excipients may not be.

10

Which of the following is an oral agent that is FDA-approved for the treatment of MS?

A. Alemtuzumab (Campath)
B. Fingolimod (Gilenya)
C. Cyclophosphamide (Cytoxan)
D. Methotrexate (Rheumatrex)
E. Rituximab
 

B. All of the above agents are used for MS, but only Fingolimod (Gilenya) has the approval.

Oral agents for MS

teriflunomide (Aubagio): active metabolite of leflunomide: pregnacy (X), boxed warning of hepatoxicity (monitor)

fingolimod (Gilenya): sensitive to moisture, CI in recent cardiovascular events (within 6 months), first dose must be given in doctor's office because profound decrease in heart rate, monitor BP HR and ECG. Remember that this drug has lots of heart problems and the "len" in Gilenya causes macular edema (eye exam)

dimethyl fumarate (Tecfidera): GI events (NVD, abdominal pain, dyspepsia) can be mitigate by titrating dose and taking it after a large meal (large breakfast and dinner since dosed BID). SE: flushing (40%) can give aspirin to reduce flushing.

dalfampridine (Ampyra): does not work for everyone, it primarily improves walking. CI in seizures or hx of seizures

natanlizumab (Tysabril): given IV every 4 weeks, know PML boxed warning (progressive multifocal leukoencephalopathy). Stable in NS only and requires protection from light

alemtuzumab (Lemtrada, Campath): first course is 12mg IV (over 4 hours) x 5 days, then second course is 12mg IV x 3 days 12 month after first course. Indicated only for refractory cases to MS drugs (tried and failed 2 or more drugs). Premedicate to reduce infusion-related reactions.

11

The pharmacist will counsel a patient beginning etanercept therapy. Choose the correct statement:

A. Etanercept is injected subcutaneously (SC) under the skin of the thigh, abdomen, or upper arm.
B. Store in the freezer.
C. The injection is given daily.
D. Shake the vial prior to injecting.
E. Etanercept must be administered by a healthcare professional.
 

A. The correct instructions are to allow the medicine to warm to room temperature before injecting (takes 15-30 minutes). Etanercept and the other biologic injectables used for RA are refrigerated (etanercept can be left at room temperature for up to 14 days). Do not shake the vial to warm it, but do instruct the patient to allow it to sit for 15-30 minutes prior to injecting. It is painful (more swelling) if a cold substance is injected. They are self-injected (SC).

Biologic DMARDs

2 categories: TNF and non-TNF

Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line

Non-TNF inhibitors: 2nd line

Warnings: serious infections and malignancies (remember LIST)

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)

No live vaccines

Antibody induction: may develop antibodies against these agents which reduces efficacy

Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)

Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs

 

Anti-TNF

etanercept (Enbrel) – Anti-TNF, 50mg SC weekly

adalimumab (Humira): 40mg SC every other week, or weekly when without MTX

infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions

certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks

golimumab (Simponi): 50mg SC monthly, IV requires filter

12

Which of the following drugs is not a interferon beta formulation?

A. Rebif
B. Avonex
C. Betaseron
D. Copaxone
E. Extavia
 

D. Glatiramer acetate (Copaxone) is not an interferon beta formulation, but it is (along with the others listed--which are beta interferons) a commonly used SC injectable used in the treatment of MS.

glatiramer (Copaxone): 20mg SC daily or 40mg SC 3x/week, can be stored at room temp (up to 1 month), pregnancy (B), can be injected in abdomen, thigh, back of upper arm, and buttocks

Interferon beta-1a and 1b: antiviral and antiproliferative effects

Avonex (beta-1a): IM weekly, store in refrigerator

Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator

Betaseron, Extravia (beta-1b): SC every other day, store at room temperature

Plegridy (beta-1a): SC every 14 days

Start all  of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble

13

Botox is used for localized pain and for muscle spasms in patients with MS. Which of the following statements concerning Botox is correct?

A. Botox needs to be used within 4 hours after reconstitution.
B. Botox has one indication, for upper limb spasticity.
C. Botox does not contain either human or animal product.
D. Botox makes the facial skin wrinkled, and should be used with caution in people who care about their looks.
E. Botox is onabotulinimtoxinA and is injected into muscles.
 

E. Botox is a popular drug and is used by dermatologists for "frown line" wrinkles in the forehead. It is used for a variety of medical conditions, including blepharospasm (eyelid twitching), cervical dystonia, chronic migraine, overactive bladder, strabismus (crossed-eyes) and muscle spasticity in conditions such as MS. It contains albumin, from human blood. .

14

A patient removes her MS injection device from the refrigerator. She lets the medication reach room temperature. This patient also uses insulin and she often shakes out the air bubbles prior to injecting her insulin dose. However, she does not dislodge any air bubble that she may see in her MS injection. Why is she careful not to expel any small air bubble from the MS medication?

A. It could cause the injection device to rupture if she taps on the device.
B. It would cause her to lose some of the dose.
C. The air mixes with the medication to form a suspension.
D. The air reduces the pain from the injection.
E. It is not actually air, but rather an optical illusion.
 

B. Do not dislodge the air bubble from these medications.

glatiramer (Copaxone): 20mg SC daily or 40mg SC 3x/week, can be stored at room temp (up to 1 month), pregnancy (B), can be injected in abdomen, thigh, back of upper arm, and buttocks

 

Interferon beta-1a and 1b: antiviral and antiproliferative effects

Avonex (beta-1a): IM weekly, store in refrigerator

Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator

Betaseron, Extravia (beta-1b): SC every other day, store at room temperature

Plegridy (beta-1a): SC every 14 days

Start all  of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble (may lose some of the dose)

15

Choose the correct statement concerning shaking injectable interferons used in MS:

A. Do not shake.
B. Shake vigorously for 10 seconds.
C. Shake vigorously for 30 seconds.
D. Shake vigorously for 1 minute.
E. Let stand to room temperature, and then shake for 15 seconds.
 

A. Some SC injectables are shaken, including some of the vaccines, but not these drugs. The protein components could be damaged.

Interferon beta-1a and 1b: antiviral and antiproliferative effects

Avonex (beta-1a): IM weekly, store in refrigerator

Rebif (beta-1a): SC TIW (at least 48 hours apart), store in refrigerator

Betaseron, Extravia (beta-1b): SC every other day, store at room temperature

Plegridy (beta-1a): SC every 14 days

Start all  of these agents at a lower dose and titrate up to target dose because of side effects: flu-like symptoms (can pre-medicate), if refrigerated then let stand to room temp prior to injection, do not expel small air bubble (may lose some of the dose), do not shake

16

A patient presents with symptoms characteristic of rheumatoid arthritis. The diagnosis requires lab and other tests, which will require time to evaluate. Since rheumatoid arthritis damages the joints and organs, the goal is to have a patient on a Disease-Modifying Antirheumatic Drug (DMARD) quickly, as these drugs slow down the disease process and help prevent further joint damage. DMARDs should be started within how many months of diagnosis?

A. 1 month
B. 2 months
C. 3 months
D. 6 months
E. 12 months
 

C. 

17

JC has rheumatoid arthritis and has been taking Enbrel for 1 year. He continues to experience daily symptoms and poor quality of life.  Which drug could be added to his rheumatoid arthritis regimen? (Select ALL that apply.)

A. Humira
B. Rheumatrex
C. Orencia
D. Motrin
E. Rituxan
 

B, D. Rheumatrex and Motrin can be used concurrently in this patient. The patient is already on Enbrel and should avoid concurrent use of another biologic agent. Concurrent use of biologics can increase risk of serious infection.

Rheumatrex (methotrexate)

Motrin (ibuprofen)

Humira (adalimumab): Anti-TNF

Orencia (abatacept): binds CD80 and CD86, inhibiting T cells

Rituxan (rituximab): CD20 inhibitor

18

Madeline is complaining of a grating pain in her right knee. She states that her knees hurt on and off, but the right knee pain is much worse. She does not have morning fatigue. Her finger joints are not swollen. Madeline is 60 inches tall and weighs 186 pounds. She is not physically active. Choose the most likely diagnosis for the cause of pain:

A. Rheumatoid arthritis
B. Osteoarthritis
C. Gouty arthritis
D. Ankylosing spondylitis
E. Fibromyalgia
 

B. Rheumatoid arthritis will present as bilateral (both sides)-this patient has a unilateral (right side only) presentation. She is overweight and not physically active. The extra weight will put pressure on her knee joints, leading to damage. She would not be expected to have much muscle mass to support the joints due to the low level of physical activity.

RA (rheumatoid arthritis) vs OA (osteoarthritis)

RA: Affects BOTH sides of body in JOINTs, SYMMETRICAL, CHRONIC, PROGRESSIVE, affects entire body (SYSTEMIC), can cause vascular complications like MI because vessels become more stiff as well, leads to cartilage and bone destruction

can be mild at diagnosis, or multiple places flare up

OA: Could be bilateral, but usually one joint or multiple joints or one side, not symmetrical

19

A patient will begin hydroxychloroquine therapy. Choose the correct counseling statements: (Select ALL that apply.)

A. You should not become pregnant while taking this medication
B. You will need eye exams when receiving this medication.
C. Stomach upset can occur; take the tablet with food or milk.
D. You should notice symptom improvement within 2-3 days of starting therapy.
E. Contact your doctor if you have any visual changes, including blurred vision and sensitivity to light.
 

B, C, E. Visual problems, including retinopathy, are a concern with the use of hydroxychloroquine. This is a commonly used medication. Counsel to take with food or milk to decrease GI upset. In addition to RA, it is used for lupus.

hydroxychloroquine (Plaquenil): more for mild-moderate disease, can be used in combo

Dosed daily, take with food or milk

Pregnancy (C)

SE: GI upset, NVD, abdominal pain, vision changes (eye exam), pigmentation of skin and hair

CI: retinopathy

20

A patient is receiving Humira. Choose the correct statement/s regarding Humira: (Select ALL that apply.)

A. The medication is injected intravenously, once weekly or every other week.
B. Humira can suppress tuberculosis infections.
C. The generic is adalimumab.
D. It can be administered in combination with methotrexate.
E. It can be administered in combination with infliximab.
 

C, D. Similar to etanercept (Enbrel) this medication comes in a syringe (or vial) and is administered by subcutaneous injection. All drugs in this group can reactivate TB infections, and can cause other serious infections since they suppress the immune system. Patients should never receive more than 1 biologic agent concomitantly.

Anti-TNF

etanercept (Enbrel) – Anti-TNF, 50mg SC weekly

adalimumab (Humira): 40mg SC every other week, or weekly when without MTX

infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions

certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks

golimumab (Simponi): 50mg SC monthly, IV requires filter

21

KT has rheumatoid arthritis, hypertension, and asthma.  She takes Enbrel, Tylenol, hydrochlorothiazide, Flovent, Proair HFA, and a daily multivitamin. Which vaccines can she receive at this time?

A. Zostavax
B. Fluzone
C. Engerix-B
D. Pneumovax
E. FluMist
 

B, C, D. Because TNF inhibitors work by blocking the immune system, they lower the patient’s ability to fight infection. Therefore, patients using TNF inhibitors should not be given live vaccines such as Flumist or Zostavax.

Enbrel (etanercept) - Anti-TNF, 50mg SC weekly

Biologic DMARDs

2 categories: TNF and non-TNF

Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line

Non-TNF inhibitors: 2nd line

Warnings: serious infections and malignancies (remember LIST)

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)

No live vaccines

Antibody induction: may develop antibodies against these agents which reduces efficacy

Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)

Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs

22

A patient is taking hydroxychloroquine, methotrexate, magnesium, calcium, raloxifene and atorvastatin. She reports that her mouth, including her gums, are sore. Upon inspection, the oral cavity appears inflamed. This complaint is most likely due to the following medication:

A. Hydroxychloroquine
B. Methotrexate
C. Raloxifene
D. Atorvastatin
E. Magnesium
 

B. When used weekly for rheumatoid arthritis, the most common side effects of methotrexate are stomatitis, nausea and diarrhea. RA patients can also experience liver toxicity, especially with long-term use. Chemotherapy doses, which are typically given IV, are more likely to result in liver, pulmonary or other toxicities, including bone marrow suppression. Stomatitis also occurs with IV administration.

Non-biologic DMARDs

methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD

Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose

SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, alopecia (using auto-injector can bypass GI problems)

CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)

Folic acid supplementation on the day after MTX

In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.

23

CM is a 35 y/o female presenting with fatigue, arthralgia, and a butterfly rash over the bridge of her nose. She has been diagnosed with systemic lupus erythematosus (SLE). Which non-pharmacologic therapies should the pharmacist recommend for CM to reduce triggering SLE flares? (Select ALL that apply.)

A. Avoid exercise which may exacerbate arthralgias
B. Avoid smoking which may trigger the disease
C. Avoid drugs that may induce SLE
D. Avoid prolonged exposure to the sun to reduce photosensitivity
E. Avoid citrus foods as they have been shown to trigger disease
 

B, C, D. Smoking and many drugs may induce or exacerbate SLE. Patients with SLE should avoid prolonged exposure to the sun.

Systemic Lupus Erythematosus (SLE)

Female, 15-45 years, African American

Butterfly rash (not painful), photosensitivity, joint pain, fatigue, weight loss

Lupus nephritis, hematologic and neurologic problems

Drug-induced Lupus Erythematosus (DILE): procainamide is most common drug that causes this, hydralazine (alone and in BiDil)

24

CY is a 38 y/o Asian female with history of rheumatoid arthritis, GERD, breast cancer, and high cholesterol. She is taking multiple medications and wants to start trying for a baby. Which of the following medications are Pregnancy Category X? (Select ALL that apply.)

A. Leflunomide
B. Pantoprazole
C. Methotrexate
D. Tamoxifen
E. Pravastatin
 

A, C, E. Pantoprazole is Pregnancy Category B. Tamoxifen is Pregnancy Category D.

leflunomide (Arava) - DMARD

methotrexate (Rheumatrex, Trexall) - DMARD

pantoprazole (Protonix)

tamoxifen (Nolvadex)

pravastatin (Pravachol)

25

A patient gave the pharmacist a prescription for Arava 20 mg daily. Which of the following is an appropriate generic substitution for Arava?

A. Leflunomide
B. Etanercept
C. Adalimumab
D. Infliximab
E. Certolizumab
 

A. The generic name of Arava is leflunomide.

etanercept (Enbrel) - anti-TNF, SC

adalimumab (Humira) - anti-TNF, SC

infliximab (Remicade) - anti-TNF, IV

certolizumab (Cimzia) - anti-TNF, SC

26

A patient gave the pharmacist a prescription for Plaquenil 200 mg daily. Which of the following is an appropriate generic substitution for Plaquenil?

A. Minocycline
B. Sulfasalazine
C. Hydroxychloroquine
D. Leflunomide
E. Adalimumab
 

C. The generic name of Plaquenil is hydroxychloroquine.

minocycline (Minocin, Solodyn)

sulfasalazine (Azulfidine, Sulfazine)

leflunomide (Arava)

adalimumab (Humira)

27

Methotrexate can cause the following adverse effects: (Select ALL that apply.)

A. LFT elevations
B. Mucositis
C. Alopecia
D. Photosensitivity
E. Nausea/vomiting
 

A, B, C, D, E. Methotrexate can cause liver, pulmonary and hepatic damage. It can cause mucositis, nausea and diarrhea. If using for psoriasis, caution patient that the drug will make them more likely to burn--patients with psoriasis may be using UV light to help control the condition.

Non-biologic DMARDs

methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD

Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose

SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, mucositis alopecia (using auto-injector can bypass GI problems)

CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)

Folic acid supplementation on the day after MTX

In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.

28

A patient is being started on Gilenya for multiple sclerosis. What are the initial monitoring parameters required with the use of this medication? (Select ALL that apply.)

A. Respiratory rate
B. Heart rate
C. Pain Score
D. Liver function tests
E. ECG
 

B, D, E. HR, LFTs and ECG are recommended initial monitoring parameters.

fingolimod (Gilenya): sensitive to moisture, CI in recent cardiovascular events (within 6 months), first dose must be given in doctor's office because profound decrease in heart rate, monitor BP HR LFTs and ECG. Remember that this drug has lots of heart problems and the "len" in Gilenya causes macular edema (eye exam)

29

CY is a 38 y/o Asian female with history of rheumatoid arthritis. Patient complained of pain/swelling in her fingers, wrists, knees, and hip in 2004, and was diagnosed with RA in April 2005. Since then, she has been on multiple agents: gold, methotrexate, prednisone, infliximab (progressed on medication), and was switched to etanercept (but had experienced a severe reaction). She is here for a clinic visit and was found to have an acute episode of hepatitis and unusual bruising. 
ALL: etanercept (SOB, hypotensive) 
PMH: Allergic rhinitis GERD Osteopenia (secondary to chronic use of prednisone) Fibromyalgia Breast cancer - R breast lumpectomy 7/10 Right foot surgery 2009 - toe surgery secondary to RA PPD neg 12/2012 
FH: Father- alive with diabetes and HTN Mother - alive with RA, fibromyalgia, and breast cancer Brother - alive with HTN SH: Denies smoking, drinking, and IV drug use 
Current Medications: 1. Leflunomide 20 mg daily 2. Methotrexate 2.5 mg (10 tabs weekly) 3. Prednisone 2.5 mg daily 4. Salsalate 500 mg (2 tabs BID) 5. Pantoprazole 40 mg daily 6. Tamoxifen 20 mg daily 7. Capsaicin Apply 5 times daily 8. Lidocaine 5% ointment PRN 
PE: VS: T 97.7 F HR 72, R 16, BP 134/87 Pain: 8/10 HT: 68" WT: 160 lbs 
GEN: alert, oriented, NAD 
HEENT: EOMI, PERRLA, MMM 
Neck: no JVD, no LAD noted Heart: RRR, no m/r/g 
Chest: lumpectomy scarring Lungs: clear to auscultation b/l, no wheezes/rhonchi/crackles 
Abdomen: non-distended, non-tender, +BS Ext: no edema 
Skin: Scratched area L thigh (healing) 
Musculoskeletal: 28 joints - more inflamed than before, synovitis at R wrist, diffuse tenderness, now esp MCPs 
Labs: WBC: 2.9 (4-11 cells/mm3) HGB: 10.8 (Male: 13.8-17.2 g/dL Female: 12.1-15.1 g/dL) HCT: 31.6 (Male: 40.7-50.3% Female: 36.1-44.3%) MCV: 107.7 (80-100 µm) PLT: 50 (140-400 x 103/mm3) GLU: 135 (65-99 mg/dL) NA: 140 (135-145 mEq/L) K: 4.2 (3.5-5.3 mEq/L) CL: 103.8 (98-110 mEq/L) CO2: 29 (21-33 mmHg) BUN: 12 (7-25 mg/dL) CRE: 0.88 (0.6-1.2 mg/dL) CALCIUM: 8.4 (8.6-10.2 mg/dL) Rheum Factor: 90 (<40 IU/mL) AST: 111 (10-35 IU/L) ALT: 130 (6-40 IU/L) 
A/P: CY is a 38 y/o Asian female with Hx of erosive deforming RA since 4/05. Past Rx included IM gold, methotrexate, prednisone, infliximab and etanercept. Current regimen prednisone 2.5 mg daily (after recent taper for flare), methotrexate 25 mg weekly (increased from 15 mg in fall 2010) and leflunomide 20 mg daily, Not on any new meds since last reaction to etanercept. Holding therapy until hepatitis and thrombocytopenia resolves. 
Upon review of CY's medication list, which of the following drugs are most likely contributing to the hepatitis? (Select ALLthat apply.)

A. Leflunomide
B. Methotrexate
C. Prednisone
D. Pantoprazole
E. Lidocaine
 

A, B. Both leflunomide and methotrexate can cause acute hepatitis.

Non-biologic DMARDs

methotrxate MTX (Rheumatrx, Trexall): the gold standard DMARD

Know dose is 7.5-25mg once WEEKLY for RA, can split up the dose

SE: GI upset, nausea, vomiting, photosensitivity, stomatitis, mucositis alopecia (using auto-injector can bypass GI problems)

CI: pregnancy (X), chronic liver disease (boxed warning is hepatotoxicity)

Folic acid supplementation on the day after MTX

In rheumatoid arthritis, MTX is taken on a WEEKLY basis. Know this because only in cancer will MTX be dosed daily and at extremely higher doses.

leflunomide (Arava): for moderate disease

Boxed warning: pregnancy (X), hepatoxicity

Dose: 100mg PO x3 days, then 20mg daily

Prodrug: active metabolite is teriflunomide (Aubagio, used in MS)

30

BH's doctor is inquiring about rituximab for RA. She was thinking this may be the next option should BH fail Orencia. She asks you about the boxed warnings for rituximab. Which of the following is not a boxed warning for rituximab?

A. Fatal infusion reactions
B. Cardiotoxicity
C. Progressive multifocal leukoencephalopathy
D. Severe mucocutaneous reactions
E. All of these are boxed warnings for rituximab
 

B. Cardiotoxicity is the only choice that is not a boxed warning for rituximab.

rituximab (Rituxan): use with MTX, binds CD20 on B cells, Boxed warning: infusion reactions (fatal), PML (progressive multifocal leukoencephalopathy due to JC virus infection, HBV reactivation, fatal mucocutaneous reactions (SJS, TEN)

31

The pharmacist is dispensing etanercept injection to a patient who has not used this medication previously. Counseling points should include: (Select ALL that apply.)

A. Store the medicine in the refrigerator or you can leave it at room temperature for up to 14 days.
B. You should receive the flu shot or FluMist each fall.
C. Shake the syringe prior to administration.
D. You should be screened initially and annually for TB.
E. Allow the product to come to room temperature before injecting.
F. Check for particles or discoloration.
G. This drug may increase your risk for lymphomas.

A, D, E, F, G. Patients on TNF-blockers should receive the annual flu shot each fall, but cannot receive the FluMist nasal mist because it is a live vaccine and patients on immunosuppressants cannot receive live vaccines. TB screening must be done at baseline and annually. Use of TNF inhibitors may increase patient's risk for serious infections and malignancies.

32

Carson has rheumatoid arthritis and has been using prednisone 10 mg daily for two years. She has been told to stop the medication due to significant side effects. She believes it may be possible to stop the prednisone as she is having a good response to methotrexate. Choose the correct statements concerning prednisone: (Select ALL that apply.)

A. She should remain on the prednisone indefinitely.
B. She will require a slow taper in order to discontinue the prednisone
C. She should be evaluated for high blood pressure and elevated blood glucose.
D. She should discontinue the prednisone immediately.
E. She is at high risk right now for low bone density.
 

B, C, E. This patient will require a prednisone taper. She is at risk for hypertension, hyperglycemia, and osteoporosis.

33

Which of the following medications can be used to treat mild systemic lupus erythematosus?

A. Etanercept
B. Cyclophosphamide
C. Abciximab
D. Hydroxychloroquine
E. Minocycline
 

D. Hydroxychloroquine is used for the treatment of mild systemic lupus erythematosus. Minocycline can cause SLE.

SLE drugs:

steroids

cyclophosphamide, azathioprine, mycophenolate, cyclosporine for severe disease

belimumab (Benlysta) - monoclonal antibody

etanercept (Enbrel) - anti-TNF

abciximab (Reopro)

hydroxychloroqine (Plaquenil) - DMARD

minocycline (Minocin, Solodyn) - DMARD

34

Celiac disease that is not recognized and not treated (with an abstention of all gluten intake) can result in the following complications (Select ALL that apply.)

A. Vitamin deficiencies
B. Anemia
C. Hirsutism
D. Lymphoma
E. Osteoporosis
 

A, B, D, E. Hirsutism (coarse hair that grows where it would normally come in as fine (thin) hair) can be due to drugs (phenytoin, danazol, steroids) or medical conditions that cause excessive androgen growth, including polycystic ovary syndrome. It is not caused by celiac. The other conditions mentioned are primarily due to decreased absorption.

35

Exacerbation of celiac disease can include the following symptoms: (Select ALL that apply.)

A. Diarrhea
B. Constipation
C. Weight Loss
D. Weight Gain
E. Abdominal pain/cramping/bloating
 

A, B, C, E. Adults more commonly get diarrhea with celiac disease; children more commonly get constipation. Either can be present. Abdominal discomfort will be evident.

36

Angie presented to the clinic with morning stiffness and significant fatigue. She complained that her finger joints were swollen and she felt achy all over. Her other complaints include urinary incontinence and depression. Lab values indicate a positive rheumatoid factor. Which of the following are consistent with a diagnosis of rheumatoid arthritis? (Select ALL that apply.)

A. Positive rheumatoid factor
B. Swollen, painful joints
C. Urinary incontinence
D. Morning stiffness
E. Depression
 

A, B, D. Diagnostic criteria for RA include the following: Morning stiffness around joints lasting greater than 1 hour, soft tissue swelling (arthritis) in 3 or more joints, swelling (arthritis) of hand, foot, or wrist joints, symmetric involvement, subcutaneous nodules, positive serum rheumatoid factor (~70% of patients) and radiographic erosions or osteopenia in the hand or wrist joints.

37

Which one of the following medications is not in the same drug class as etanercept?

A. Humira
B. Rituximab
C. Cimzia
D. Simponi
E. Remicade
 

B. Rituximab is an anti-CD 20 monoclonal antibody

Anti-TNF

etanercept (Enbrel) – Anti-TNF, 50mg SC weekly

adalimumab (Humira): 40mg SC every other week, or weekly when without MTX

infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in HF, delayed hypersensitivity reactions, infusion reactions

certolizumab (Cimzia): 400mg SC at 0, 2, 4, then 200mg SC every other week or 400mg SC every 4 weeks

golimumab (Simponi): 50mg SC monthly, IV requires filter

38

Gerry has had mild rheumatoid arthritis for many years. She failed methotrexate due to elevated liver enzymes. Fortunately, her liver enzymes returned to normal after the drug was discontinued. The physician suggested that she try etanercept injections, but she refused to self-inject. What medication would be a reasonable option to try next to help control disease progression and reduce joint damage?

A. Hydroxychloroquine
B. Celecoxib
C. Ibuprofen
D. Nabumetone
E. Infliximab
 

A. Hydroxychloroquine (Plaquenil) is not hepatotoxic and would be a good choice for a patient with mild-moderate RA. NSAIDs do not control the disease or reduce joint damage; they are for symptom relief only. They can be useful, but the patient needs DMARD therapy so that her disease does not progress more than is necessary.

infliximab (Remicade): IV infusion (0, 2, and 6, and then every 8 weeks), need filter and compatible with NS only, lower dose in - anti-TNF

39

BH is a 45 y/o male with worsening rheumatoid arthritis. He weighs 75 kg and is 5'10". In the past, he has tried celecoxib, prednisone, oral methotrexate, etanercept, and infliximab. The doctor would like to try Orencia. Which of the following statements are true regarding Orencia?

A. Orencia is the brand name of tocilizumab.
B. Orencia cannot be used concurrently with other biologic agents.
C. Patients taking Orencia can safely receive live vaccines.
D. Patients do not have to be screened for latent TB prior to receiving Orencia
E. Orencia is a tumor necrosis factor inhibitor.
 

B. Orencia is the brand name of abatacept and works by inhibiting T lymphocytes. The dose is based on weight and can be given IV or SC.

abatacept (Orencia): bines CD80 and CD86, inhibiting T cells, screen for TB and HBV

40

Many patients with multiple sclerosis inject immune modulating drugs themselves. These drugs are primarily given subcutaneously. Which of the following represent the two common sites that patients use to self-inject SC?

A. Triceps, abdomen (pull skin tight, away from navel)
B. Deltoid, abdomen (pull skin tight, away from navel)
C. Front of thighs, abdomen (pull skin tight, away from navel)
D. Fatty tissue near triceps, abdomen (pull skin tight, away from navel)
E. Gluteus maximus, abdomen (pull skin tight, away from navel)
 

C. The fatty tissue near the triceps is a common place to inject SC vaccines, but patients usually inject in the front of the thighs or abdomen.

41

MA recently visited her healthcare provider and was diagnosed with Raynaud’s Phenomenon. What is the classic symptom of Raynaud’s Phenomenon? 

A. Hypertension
B. Cold, blue fingers and toes
C. Photosensitivity
D. Chest pain
E. Migraines
 

B. The classic symptoms of Raynaud’s Phenomenon are cold, blue fingers and toes.

Raynaud's

Cold or stress can trigger vasospasm of small blood vessels. Skin turns white then to blue fingers and toes. When warmed, painful swelling can occur in hands and feet.

Drug of choice are calcium channel blockers. Nifedipine is commonly used for prevention.

42

Sharon is a 32 year-old patient with rheumatoid arthritis who has had two unplanned pregnancies during her twenties. Both pregnancies were terminated. She is now married and had an unplanned pregnancy two years ago, which resulted in a live birth. Sharon started treatment with methotrexate 10 months ago. The treatment is partially effective. Her pain has been lowered, but her joints show further radiographic erosions. She does not believe in using birth control. The physician will begin a second agent. He is considering using either leflunomide or etanercept. Choose the correct statement:

A. Methotrexate can cause miscarriage and is not a safe choice in this patient.
B. Leflunomide is a safe choice in this patient.
C. If she uses methotrexate she will need to wait two years after stopping to become pregnant, or can use cholestyramine to eliminate the drug from her body sooner.
D. Etanercept is contraindicated in pregnancy
E. The dose of methotrexate should be increased to 50 mg/m2
 

A. Both methotrexate and leflunomide are unsafe choices; methotrexate can induce miscarriage, and leflunomide is teratogenic. If she uses leflunomide she must have a negative pregnancy test prior to starting treatment and will need to wait two years after stopping to become pregnant, or she can use cholestyramine to eliminate the drug from her body sooner.

43

A patient with rheumatoid arthritis wishes to begin therapy with adalimumab. She was tested for tuberculosis. The skin test was positive, but her chest X-ray was negative. She is diagnosed with latent TB infection. Choose the correct statement:

A. She has latent TB disease; no treatment is required.
B. She will need to begin TB treatment prior to starting adalimumab.
C. She has a contraindication to adalimumab therapy.
D. She will require etanercept therapy instead due to her positive TB skin test.
E. She will require rituximab therapy instead due to her positive TB skin test.
 

B. Patients who test positive for TB via the skin test will need to be treated prior to starting a biologic agent.

44

Carson, a patient with a diagnosis of rheumatoid arthritis, was never prescribed DMARD therapy. Instead, she received prednisone long-term. In addition to disease progression, she was put at risk for the following side effects of steroid therapy: (Select ALL that apply.)

A. Impaired wound healing
B. Diabetes
C. Osteoporosis
D. Hyperglycemia
E. Cataracts
 

A, B, C, D, E. These are some of the many side effects associated with corticosteroid use.

45

A patient is being started on Aubagio for multiple sclerosis. Which of the following statements is correct regarding Aubagio?

A. Aubagio is Pregnancy Category X.
B. Aubagio is safe in patients with liver impairment.
C. The generic name is leflunomide.
D. It works by inhibiting purine synthesis
E. It is available as an IM injection.
 

A. Teriflunomide (Aubagio) is an oral pyrimidine synthesis inhibitor that is pregnancy category X.

leflunomide (Arava) - used in RA, but active metabolite is teriflunomide so same warnings

Boxed warning: pregnancy (X), hepatoxicity

Dose: 100mg PO x3 days, then 20mg daily

Prodrug: active metabolite is teriflunomide (Aubagio, used in MS)

46

Marsela has been coming to the same pharmacy for many years. She tells the pharmacist that she just feels down and cannot get out of bed in the morning because her body feels stiff all over. In addition, she has had thinning hair and brittle nails. Marsela complains that she has become short-tempered with her husband. She finds, as well, that her monthly periods seem heavier and more painful. Which of the following symptom in this patient might lead the pharmacist to question if she might have rheumatoid arthritis?

A. Morning stiffness
B. Thinning hair, brittle nails
C. Anger, short temper
D. Heavy menstrual periods
E. Cramping during menses
 

A. Morning stiffness is a hallmark sign of rheumatoid arthritis. Depression can also be present, which might lead her to feel badly about other issues.

47

What is first line treatment for Raynaud’s Phenomenon?

A. Angiotensin receptor blockers
B. Phosphodiesterase inhibitors
C. Calcium channel blockers
D. ACE inhibitors
E. Statins
 

C. Calcium channel blockers, such as extended release nifedipine, are often used first line to manage Raynaud’s Phenomenon.

Raynaud's

Cold or stress can trigger vasospasm of small blood vessels. Skin turns white then to blue fingers and toes. When warmed, painful swelling can occur in hands and feet.

Drug of choice are calcium channel blockers. Nifedipine is commonly used for prevention.

48

EW is a patient with active systemic lupus erythematosus. Which of the following medications is indicated for the treatment of active systemic lupus erythematosus in addition to standard therapy?

A. Benlysta
B. Simulect
C. Regranex
D. Treanda
E. Survanta
 

A. Benlysta (belimumab) is a B-lymphocyte stimulator (BLyS)-specific inhibitor indicated for the treatment of adult patients with active, autoantibody-positive, systemic lupus erythematosus who are receiving standard therapy.

Simulect (basiliximab)

Regranex (becaplermin)

Treanda (bendamustine)

Survanta (beractant)

49

What is the primary cause of multiple sclerosis (MS)?

A. MS is thought to be due to toxin exposure; high levels of lead and mercury are found in the blood of MS patients.
B. MS is thought to be due to age; this disease primarily affects patients older than 70 years of age.
C. MS is an auto-immune disease; the patient's immune system attacks the myelin peptide antigens, destroying the fatty myelin sheaths in the CNS. This reduces nerve transmission.
D. MS is an auto-immune disease; the patient's immune system attacks the salivary glands in the mouth and the thyroid gland in the neck.
E. MS is an auto-immune disease; the patient's immune system attacks brain cells in the substantia nigra region.
 

C. As demyelination progresses, the symptoms worsen because the nerves can no longer properly conduct electrical transmission.

Multiple Sclerosis (MS): T cells attack the myelin sheaths that surround axons in the brain and spinal cord.

Symptoms: weakness, tingling/pain, blurred vision, depression, problems with balance and walking, muscle spasms, changes in vision, poor muscle coordination, sexual problems, bladder and bowel problems

50

Taclonex is a popular dermatological drug. Taclonex is used for this condition:

A. Psoriasis
B. Acne
C. CA-MRSA
D. Poison ivy, oak or sumac
E. Eczema
 

A. Calcipotriene and betamethasone ointment comes as Taclonex and Taclonex scalp suspension. Calcipotriene comes alone as Dovonex. Calcipotriene is a vitamin D analog.

51

Select the common side effect from injections for any condition that most patients who self-administer are likely to experience:

A. Tuberculosis
B. Malignancies
C. Heart failure decompensation
D. Redness, swelling, itching and/or mild pain
E. Arthralgias
 

D. Whatever the injection used, the injection site can hurt, and a common side effect from any injection is redness, swelling, itching and/or mild pain.

52

A patient removes her Rebif injection device from the refrigerator. The pharmacist has counseled her to take the medication from the refrigerator and place it into a kitchen cabinet. Why did the pharmacist offer this advice? (Select ALL that apply.)

A. It can take a while to reach room temperature.
B. It should not be left in the open where young children might handle the device.
C. It must be protected from light during the time it is reaching room temperature.
D. It is more likely the patient will forget to inject the medication.
E. This is safer than leaving it in the refrigerator because the electricity could go out.
 

A, B. It can take several hours to reach to room temperature. It is best to store it out of reach of others, including children.

53

Natalizumab (Tysabri) is an effective agent for treating MS, but is not a first-line agent due to the risk of the following adverse drug reaction:

A. Progressive Multifocal Leukoencephalopathy
B. Tabes dorsalis
C. Optic neuritis
D. Acute renal failure
E. Nerve Demyelination Syndrome
 

A. Natalizumab (Tysabri) is a humanized monoclonal antibody. Results from clinical trials with natalizumab show a larger reduction in relapse rates, however it is used only in patients who could not tolerate or had poor response to other agents because it is associated with an increased risk of progressive multifocal leukoencephalopathy (PML), a rare, opportunistic, viral brain infection that can cause death or severe disability.

natanlizumab (Tysabril): given IV every 4 weeks, know PML boxed warning (progressive multifocal leukoencephalopathy). Stable in NS only and requires protection from light

54

Which of the following are side effects associated with cyclophosphamide therapy when treating patients with systemic lupus erythematosus? (Select ALL that apply.)

A. Nephrolithiasis
B. Hemorrhagic cystitis
C. Bone marrow suppression
D. Infertility
E. Infections
 

B, C, D, E. Cyclophosphamide can cause bone marrow suppression leading to severe infections, hemorrhagic cystitis, and fertility problems (among others).

Remember it's a chemo-agent so it causes bone marrow suppression and hence decreased WBC leading to infections. Chemo-agents also stop cell cycle so germ cells cannot divide (infertility). Often given with MESNA to reduce hemorrhagic cystitis.

55

The following tests should be checked prior to initiating etanercept or other TNF-inhibitor therapy: (Select ALL that apply.)

A. White blood cell count
B. TB test
C. Liver enzymes
D. Pulmonary function tests
E. 24-hour urine collection
F. HBV
 

A, B, C, F. These drugs cannot be started if the patient has a current infection (the white blood cell count, or WBC, will be elevated) or if TB is identified (until treatment has begun) or if liver enzymes are elevated.

Biologic DMARDs

2 categories: TNF and non-TNF

Tumor necrosis factor (TNF) inhibitors (Anti-TNF): 1st line

Non-TNF inhibitors: 2nd line

Warnings: serious infections and malignancies (remember LIST)

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

Do not shake; refrigerate; bring to room temp before injecting (to reduce pain)

No live vaccines

Antibody induction: may develop antibodies against these agents which reduces efficacy

Infusion related reactions (reduce with pre-medications like NSAIDs or Tylenol)

Screen for TB, HBV, infections, HF (Class III/IV), CBC, LFTs

56

Which of the following statements regarding tofacitinib is correct?

A. It is a new injectable biologic agent indicated for the treatment of rheumatoid arthritis
B. It has a boxed warning for the risk of fetal abnormalities
C. It should be used with a biologic DMARD
D. It is an inhibitor of Janus kinase
E. The brand name is Aubagio
 

D. Tofacitinib (Xeljanz) is an inhibitor of Janus kinase (JAKs). It is an oral medication that is taken BID. Tofacitinib is Pregnancy Category C and should not be used with biologic DMARDS or other potent immunosuppressants like cyclosporine or azathioprine.

tofacitinib (Xeljanz): inhibitor of Janus kinase enzyme (JAKs) for moderate-severe RA

CYP interactions (must decrease dose with potent 3A4 and 2C19 inhibitors)

Boxed warning: serious infections and malignancies (remember LIST acronym)

Do not use with biologic DMARDs or potent immunosuppressants

L – lymphomas, I – infections , S – skin cancer, T – tuberculosis

57

What is the active ingredient in Restasis?

A. Tacrolimus
B. Cyclosporine
C. Mycophenolate
D. Polyethylene glycol 3350
E. Pilocarpine
 

B. Cyclosporine opthalmic (Restasis) can be used in patients with severe dry eyes from Sjogren's syndrome.

Decks in Pharmacy Class (61):