Corticosteroids Flashcards
Disease Modifying Anti-Rheumatic
DMARDS
Hydrocortisone (CORTEF)
Dexamethasone (DECADRON)
Prednisone (DELTSONE)
Prednisolone (PRELONE, PEDIAPRED)
Methylprednisolone (MEDROL)
Corticosteroids
Corticosteroids: Indications
Replacement: Addison’s Disease (low dose)
Non-endocrine (high dose)
- RA, SLE
- Asthma
- Inflamm. Bowel Disease
- Severe allergic responses
- Dermatologic conditions
- Respiratory support in preterm
infants
-Cerebral edema
Systemic Corticosteroids
Use in dermatologic disease
Life threatening disease – pemphigus vulgaris (auto-immune etiology)
Self-limited disease – poison ivy (Rhus dermatitis)
Prednisone taper (40,30,20,10,5)
Corticosteroids – adverse reactions
Mild euphoria/depression
Insomnia
Exogenous Cushing’s syndrome
GI distress (peptic ulcers)
impaired skin healing
Osteoporosis
Precipitation of diabetes
Infections (fungal and bacterial)
Topical Corticosteroids – Pharmacodynamics
Effects
Anti-inflammatory- decreases prostaglandins, leukotrienes, suppresses mast cells
Inhibits migration of macrophages and leukocytes
Vasoconstriction
Alterations of Efficacy – strength ≠ efficacy
Absorption: dependent of thickness (intertriginous, facial), hydration of skin (occlusive dressings absorbed more rapidly)
Topical Corticosteroids Indications
-Dermatitis: atopic, contact, nummular, seborrheic
-Lichen planus
-Lupus erythematosus, discoid Lupus
-Xerosis - inflammatory phase
-Pruritus
-Alopecia areata
-Pityriasis rosea
-Sarcoidosis
-Pemphigus
-Psoriasis
-Sunburn
In general: used for any inflammatory, erythematous process that occurs in the skin, EXCEPT FOR SUSPECTED INFECTIOUS PROCESS!!!
Atopic Dermatitis
Immunologically mediated dermatitis (inflammation) of the dermis
Eczema
Chronic allergic condition that usually starts early in life
More than 50% of people with atopic dermatitis later develop asthma and 75% develop allergic rhinitis
Atopic Dermatitis Pearls
Appx 80 – 85 % of AD patients have ↑ levels of IgE
Have skin test rxns to inhaled and food allergens
most adults with AD do not have actual food allergies ???
Suggests inhaled allergens as the culprit
-Facial involvement is normal on infants
-Antecubital
-Can occur on hands and feet
Topical Corticosteroids – Adverse Reactions
Systemic effects
Atrophy (thin, transparent)
Skin bleaching
Striae
Telangiectasias
Purpura
Acneiform eruptions
Steroid rosacea
Glaucoma/cataracts
Growth suppression (in children)
Rebound flare
Topical Corticosteroids – patient education
Side effects: skin thinning
Keeping away from eyes
Avoid facial application except very sparingly and with low potency cream
Not bandaging or otherwise wrapping
Proper use of occlusive dressing, if prescribed
Disease modifying anti-rheumatic drugs (DMARDS):
1) Conventional
2) Biologics
Conventional DMARDS
Methotrexate
Hydroxychloroquine
Leflunomide
Sulfasalazine
Methotrexate
MOA:
Inhibits cytokine production (TNF, interleukins)
Stimulates adenosine release (potent anti-inflammatory mediator)
Folic acid antagonist which DNA synthesis in cancer cells at higher doses
INDICATION: Rheumatologic disease
DMARD of 1st choice!
Methotrexate SE
Nausea and vomiting
Folate deficiency
Oral ulcerations
Headaches
Fatigue (“methotrexate fog”)
Liver fibrosis
Contraindication: pregnancy
Mitigation of SEs
Folate supplementation
Splitting the dose
Switch to injectable version
Ondansetron
Lidocaine mouth swish
Hydroxychloroquine (Plaquenil)
MOA (RA, SLE): blocks the stimulation of CD4 T cells,
down –regulation of the immune response
MOA (malaria prophylaxis and tx): increases levels of cytotoxic heme (Fe containing compound in HGB) which accumulates in parasites – Plasmodium genus
EUA: Covid 19 – revoked in June 2020 2nd to lack of evidence
TNF ⍺ Antagonists
(Tumor necrosis factor ⍺ antagonists, “biologics”)
TNF ⍺ Antagonists
Suppress the physiologic response of TNF ⍺ which is part of the inflammatory response
Used in autoimmune diseases which trigger the excessive production of TNF ⍺
Used in RA, Crohn’s Disease, psoriasis, psoriatic arthritis
TNF Antagonists
infliximab(Remicade)
adalimumab(Humira)
certolizumab pegol (Cimzia)
golimumab (Simponi)
etanercept(Enbrel)
TNF Side Effects
Injection site reactions (common)
Infections – TB – need to screen for latent or active TB
Live attenuated vaccines contraindicated
Neutropenia
Paradoxical immune diseases (psoriasis)
Malignancy (lymphoma, skin cancer)
Neurologic complications – should not be given to MS patients
Exacerbation of heart failure
Very expensive!
Biologics vs. Biosimilars
Biologics are made from living cells – blood, proteins, antibodies, viruses or other living organisms
Used for immune diseases, cancer, diabetes
Biosimilars are also made from living cells and are similar to the biologics.
Same potency, dose, SE, and administration
But not identical like generics
