Chapter 46: Systemic Steroids & Autoimmune Conditions Flashcards
(115 cards)
1
Q
What are the three commonly used adrenal hormone replacement therapies?
A
Hydrocortisone, cortisone, prednisolone
2
Q
Which adrenal hormone replacement therapy has mineralocorticoid activity?
A
Fludrocortisone
3
Q
What condition is fludrocortisone used to treat?
A
Addison’s disease and sometimes orthostatic hypotension
4
Q
What is the primary effect of glucocorticoids?
A
Anti-inflammatory effects
5
Q
What is the result of systemic steroid use on cortisol production?
A
Suppression of the hypothalamic-pituitary-adrenal (HPA) axis
6
Q
What is Cushing’s syndrome?
A
Cushing’s syndrome can develop when the adrenal gland produces too much cortisol or if exogenous steroids are taken in doses higher than normal endogenous cortisol.
7
Q
What condition is considered the opposite of Cushing’s syndrome?
A
Addison’s disease
8
Q
What happens if exogenous steroids are suddenly stopped?
A
It can cause an adrenal crisis, also known as an ‘Addisonian Crisis.’
9
Q
What are the hallmarks of an adrenal crisis?
A
Volume depletion and hypotension
10
Q
What are some long-term effects of steroids?
A
- Psychiatric changes (anxiety, depression, delirium, psychoses)
- Glaucoma
- Cataracts
- Headache
- Intracranial hypertension
- Hypothyroidism
- Acne
- GI bleeding/esophagitis/ulcers
- Fat deposits (moon face, buffalo hump)
- Pink-purple stretch marks (striae)
- Thin skin that bruises easily
- Growth retardation
- Muscle wasting
11
Q
What is one way to reduce systemic steroid risks?
A
Use every other day dosing to decrease Cushing-like side effects.
12
Q
How can joint inflammation be treated to minimize steroid risks?
A
Use intra-articular injections (inject into the joint).
13
Q
What type of steroid can be used for GI conditions with low systemic absorption?
A
Delayed-release budesonide (Entocort EC)
14
Q
What type of steroids should be used for asthma treatment?
A
Inhaled steroids that mainly stay in the lungs.
15
Q
What is the recommendation for long-term steroid use?
A
Use the lowest effective dose for the shortest possible time.
16
Q
What are some effects of Cushing’s syndrome specific to women?
A
- Hair growth on face and body (hirsutism)
- Irregular or absent menstrual periods
- Poor bone health
17
Q
SYSTEMIC STEROIDS (PO, IV) DOSE EQUIVALENCE
A
Cortisone = 25mg
Hydrocortisone = 20 mg
Prednisone = 5 mg
Prednisolone = 5mg
Methylprednisolone = 4mg
Triamcinolone = 4mg
Dexamethasone = 0.75 mg
Betamethasone = 0.6 mg
18
Q
What are some short-term side effects of systemic steroids used for less than 1 month?
A
- Fluid retention
- Stomach upset
- Emotional instability
- Insomnia
- Increased appetite
- Weight gain
- Acute blood glucose/pressure increase
19
Q
Which systemic steroid is a prodrug?
A
Cortisone, prednisone
20
Q
Dexamethasone brand name?
A
Decadron
21
Q
Hydrocortisone brand name
A
Solu-cortef
22
Q
Prednisolone brand name
A
Millipred, orapred ODT
23
Q
Triamcinolone brand name
A
Kenalog
24
Q
When is a patient on systemic steroids is immunosuppression?-
A
A patient is immunosuppressed when using >= 2 mg /kg/day or >= 20 mg/day of prednisone or prednisone equivalent for >2 weeks
25
Common symptoms of most autoimmune diseases?
Fatigue, weakness and pain
26
Nonspecific laboratory blood tests that can be useful in detecting inflammation
1. erythrocyte sedimentation rate (ESR, C-reactive protein (CRP),
2. rheumatoid factor (RF) and
3. anti-nuclear antibody (ANA).
27
What is rheumatoid arthritis (RA)?
A chronic, progressive autoimmune disorder that primarily affects joints and can affect other organs such as the kidneys, eyes, heart, and lungs
28
What symptoms are consistent with diagnosing RA?
Bilateral, symmetrical inflammation
29
What is the preferred initial therapy for most RA patients?
Methotrexate (MTX)
30
What should be avoided when treating RA with biologic DMARDs?
Never use two biologic DMARDs in combination
31
What are commonly used in RA flares?
Steroids
## Footnote
RA stands for rheumatoid arthritis, a chronic inflammatory disorder.
32
How should steroids be used in RA flares?
At the lowest dose and for the shortest duration possible.
33
Methotrexate brand name
Trexall
34
Methotrexate MOA
Irreversibly binds and inhibits dihydrofolate reductase, inhibiting folate.
35
Methotrexate dosing for RA
7.5 - 20 mg once weekly
36
Methotrexate boxed warnings
Hepatotoxicity, myelosuppression, mucositis, pregnancy
37
Methotrexate monitoring
CBC, LFTs, chest X-ray, hep B & C serologies
38
How to decrease hematological, GI and hepatic side effects with methotrexate?
Folate
39
Hydroxychloroquine brand name
Plaquenil
40
Hydroxychloroquine warning?
Irreversible-retinopathy, QT prolongation
41
Hydroxychloroquine side effects
Vision changes
42
Leflonomide MOA for RA
Inhibits pyrimidine synthesis
43
Leflunomide boxed warning?
Do not use in pregnancy, hepatotoxiciten
44
How long after discontinuation of leflunomide patients can become pregnant?
2 years
45
Janus kinase inhibitors boxed warnings
Infection, malignancy, thrombosis
46
List anti-TNF DMARDs
1. Etanercept (enbrel)
2. Adalimumab (humira)
3. Infliximab (Remicade)
4. Certolizumab pegol (cimzia)
5. Golimumab (simponi)
47
How often is etanercept (enbrel) given?
SC weekly
48
How often is Humira given?
SC every other week
49
How is infliximab given?
IV
50
How often is golimumab given?
SC weekly
51
anti-TNF DMARDs boxed warning
Infection, latent TB, malignancies
52
Name a non-TNF DMARDs
Rituximab (rituxan)
53
Rituximab MOA
Depletes CD20 B cells
54
Which drugs to use for premedication for rituximab
Steroids, acetaminophen, antihistamine
55
How long etanercept and adalimumab can be stored in room temp?
14 days
56
What is a common way to taper steroids?
Reduce the dose by 10-20% every few days. Tapers can last 7-14 days.
57
What decreases renal elimination of MTX?
Aspirin and NSAIDs
58
What does Infliximab (Remicade) require for administration?
A filter and is only stable in normal saline.
59
Which anti-TNF biologic DMARD causes infusion reactions?
Infliximab (Remicade).
60
Which anti-TNF biologic DMARD causes delayed hypersensitivity reactions?
Infliximab (Remicade).
61
SLE is most common in which gender/ethnicities?
Women of AA and Asian descent.
62
What are the most common symptoms of SLE?
Fatigue, depression, anorexia, weight loss, muscle pain, malar rash (butterfly rash), photosensitivity, and joint pain and stiffness.
63
What condition develops in over 50% of patients with SLE?
lupus nephritis
64
Which common lab findings are associated with a SLE diagnosis?
positive ANA and positive anti-ssDNA and anti-dsDNA
65
Treatment for SLE can take up to ____ to see max benefit?
6 months
66
What drugs are used for chronic SLE?
hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate mofetil, and cyclosporine
67
List drugs that can cause DILE?
* Methimazole
* Propylthiouracil
* Methyldopa
* Minocycline
* Procainamide
* Hydralazine
* Anti-TNF agents
* Terbinafine
* Isoniazid
* Quinidine
68
What warnings are associated with Belimumab (Benlysta) used for SLE?
Serious infections; do not give with other biologic DMARDs or live vaccines.
69
For which population does Belimumab (Benlysta) used for SLE have a lower response rate?
AA
70
What are early symptoms of multiple sclerosis?
Fatigue, numbness, and blurred vision.
71
Glatiramer acetate brand name
Copaxone
72
Glatiramer acetate warning
chest pain
73
Glatiramer acetate side effects
injection site reactions, flushing, diaphoresis, dyspnea
74
What is the preferred agent if treatment of MS is required during pregnancy?
Glatiramer acetate
75
How is Glatiramer acetate dosed?
20 mg SC daily or 40 mg SC 3 times per week
76
How is interferon beta-1a (Avonex, Rebif) dosed?
Avonex: IM weekly
Rebif: SC 3 times per week
77
How is interferon beta-1b (Betaseron, Extavia) dosed?
SC every other day
78
How is peginterferon beta-1a (Plegridy) dosed?
SC every 14 days
79
What are warnings for interferon beta products used in MS?
Psych disorders (depression/suicide), injection site necrosis, increased LFTs, thyroid dysfunction (hyper and hypo)
80
What is a SE for interferon beta products used in MS?
Flu-like symptoms
81
T/F: Make sure to expel the small air bubble in prefilled syringes of interferon beta products.
False; you will lose the dose
82
What should be done with interferon beta products prior to injection?
Let it stand at room temperature
83
Which interferon beta products do not need refrigeration?
Betaseron and Extavia
## Footnote
These are the exceptions among interferon beta products for MS.
84
What do some formulations of interferon beta products used in MS contain?
Albumin
85
Which genotype testing is requred prior to initiating Siponimod for MS?
CYP2C9*3/*3 genotype
86
What can Sphingosine 1-phosphate receptor modulators cause?
Bradycardia or other bradyarrhythmias
87
What precaution should be taken when using other drugs that slow heart rate?
Use caution with Sphingosine 1-phosphate receptor modulators
88
How long must patients starting fingolimod be monitored after the first dose?
At least 6 hours
89
What is required at baseline and at the end of the initial observation period for patients starting fingolimod?
ECG
90
What should be monitored in patients on Sphingosine 1-phosphate receptor modulators?
CBC for infection risk
91
What should be screened for before starting Sphingosine 1-phosphate receptor modulators?
VZV antibodies
92
What should be done if VZV antibodies are negative or if there's no history of chickenpox?
Vaccinate
93
What are some other side effects of Sphingosine 1-phosphate receptor modulators?
* Malignancies
* Macular edema
* Hepatotoxicity
* Decreased blood pressure
* Lung function impairment
* Fetal risk
94
What should women of childbearing potential do while on Sphingosine 1-phosphate receptor modulators?
Use contraception during and some time after stopping therapy
95
What is a CI of teriflunomide (Aubagio)?
Pregnancy
96
Natalizumab brand name
Tysabri
97
Natalizumab boxed warning
PML; only available through the REMS TOUCH Prescribing Program
98
Drugs commonly used for symptom control in MS include:
* anticholinergics for incontinence,
* laxatives for constipation,
* muscle relaxants for muscle spasms,
* analgesics for muscle spams and pain,
* propranolol for tremor
99
Which medication class is commonly used to prevent Raynaud’s Phenomenon?
CCBs
100
What specific medication is commonly used to prevent Raynaud’s Phenomenon?
Nifedipine
101
Which drugs can cause or worsen Raynaud’s?
BB, Bleomycin, cisplatin, sympathomimetics (from vasoconstriction) like amphetamines, PSE and illicit drugs.
102
What is celiac disease?
Patients with celiac disease have gluten intolerance.
103
Celiac common symptoms
* diarrhea
* abdominal pain
* bloating
* weight loss
104
Myasthenia common symptoms
vision/eye changes, drooping eyelid
105
Which drugs can worsen or unmask myasthenia gravis
Antibiotics: AMG and quinolones
Mg salts
select antiarrhythmics
BB & CCB
Select antipsychotics
Muscle relaxants
Local anesthetics
106
What is the mechanism of action (MOA) of pyridostigmine?
It blocks the breakdown of acetylcholine (ACh).
107
What is Sjogren’s syndrome characterized by?
Severe dry eyes and dry mouth.
108
What OTC products can be used for dry eyes in Sjogren’s syndrome?
Artificial teardrops (Systane, Refresh, Clear Eyes, and Liquifem).
109
What is the brand name of cyclosporine emulsion?
Restasis.
110
Side effect of Restasis
burning of eyes
111
Lifitegrast Brand name
Xiidra
112
Side effect of Xiidra
unusual taste
113
What type of drugs can treat dry mouth in Sjogren’s syndrome?
Muscarinic agonists such as pilocarpine or cevimeline.
## Footnote
These are contraindicated in patients with uncontrolled asthma and narrow-angle glaucoma.
114
What non-drug treatment can help mild-moderate psoriasis symptoms?
UVB phototherapy
## Footnote
UVB phototherapy involves exposure to ultraviolet B light, which can reduce the symptoms of psoriasis.
115
If steroids, vitamin D analogues, anthralin, retinoids, salicylic acid, coal tar, and moisturizers fail for treatment of psoriasis, what can be used?
topical calcineurin inhibitors
## Footnote
Topical calcineurin inhibitors are used to reduce inflammatory skin conditions, including psoriasis, when first-line treatments are ineffective.
