Derm systemic meds

Question 1

Cyclosporine start labs

Answer 1

-two baseline BPs at least a day apart
-CBC w/ diff & CMP
-Two baseline creatinine level (or Cr clearance) at least a day apart

Question 2

Cyclosporine contraindications

Answer 2

-CTCL
-abn renal function
-uncontrolled HTN
-malignancies
-radiation therapy or concomitant PUVA/UVB
-MTX or immunosuppressives

Question 3

Cyclosporine pregnancy

Answer 3

Category C; new 2015 rating; probably compatible

Question 4

Cyclosporine warnings

Answer 4

-nephrotoxicity, hepatotoxicity, serous infections, transplantation patients (^malignancy)
-HTN, usually mild and generally reversible after dose reduced or d/c

Question 5

Corticosteroids contraindicated

Answer 5

-systemic fungal infections, hypersensitivity
-live vax shouldn’t be given

Question 6

Corticosteroids >4 weeks

Answer 6

-DEXA scan, Vit D 800 IU, calcium 1,200 mg, biphosphonates
- >1 gm total dose H2 antihistamines or PPIs

Question 7

MTX absolute C/I

Answer 7

-ETOH abuse, bone marrow d/o, CKD, liver dz, immuondeficiency syndromes, patients contemplating pregnancy and lactation

Question 8

MTX drug interactions HIGH risk

Answer 8

sulfonamides (dapsone),sulfamethoxazole (TMP/SMX), phenytoin, phenothiazine, NSAIDs, immunosuppressants, oral retinoids

Question 9

MTX drug interactions LOWer risk

Answer 9

tetracyclines, cholestyramine, live vax

Question 10

MTX warnings

Answer 10

-complete vax (live or recombinant) 2 wks before initiation of treatment
-monitor for preg/BF
-screen/monitor for infection
-assessment of ETOH intake

Question 11

MTX adverse effects

Answer 11

Hepatotoxicity, aplastic anemia, pancytopenia, GI sx (diarrhea, stomatitis, intestinal perforation), opportunistic or reactivation of infections, secondary malignancies. MTX pneumonitis (usu. in first 6 mons dry cough, SOB)

Question 12

MTX labs

Answer 12

Baseline: CBC w/ diff, liver/renal fxn, screen Hep B/C, TB, HIV if indicated

Follow-up: CBC & LFTs 1 wk after test dose, then q1-2 wks for month, then q3-4mons, renal fxn 1-2 yearly

Question 13

MTX liver evaluation

Answer 13

Baseline only if high-risk (NASH, obesity, HLD)
1st bx 3.5-4 g total cumulative

Question 14

General biologics guidelines

Answer 14

-baseline screen for infections (Tb, Hep B/C, HIV)
-don’t use on pts w/ acute/chronic infection
-avoid all live vax during tpy
-d/c if hypersensitivity, or serious infections

Question 15

Biologics: special pops

Answer 15

-Hepatitis B, eval by GI spec
-Hep C, confirmed and resolved (may use anti-TNF, monitor for reactivations)
-Preg/lact, greatest r/o placental transfer 3rd tri; anti-TNF safest certolizumab pegol
-Etanercept ages 4 and older
-don’t use MTX, acetretin & top tazarotene, C/i preg

Question 16

Biologics: Target specific safety issues

Answer 16

TNFa inhibitors: TB, NYHA III/IV HF, lupus, MS
IL-17 inh: candida infections, IBD
IL-12/23 ustekinumab (Stelara): exfoliative dermatitis
IL-23 p19: none

Question 17

Antivirals therapeutic recommendations
(acyclovir, valacyclovir, famciclovir)
indications for HSV & HZ

Answer 17

-may cause nephrotox (intratubular precipitation of crystals)
- ^ risk if dehydration or pre-exis renal impairment
-f/u vax should be delayed at least 2 wks p antiviral tpy

Question 18

Zoster antiviral dosing

Answer 18

acyclovir: 800 mg 5x/day x 7-10 d
valacyclovir*: 1 g TID x 7-10 d
famciclovir: 500 mg TID x 7d

Question 19

HSV primary episode

Answer 19

acyclovir: 400 mg TID x 10 d
valacyclovir: 1 g BID x 10 d
famciclovir: 250 mg TID x 10d

Question 20

Itraconazole contraindication

Answer 20

ventricular dysfunction (CHF)

Question 21

Oral ketoconazole

Answer 21

black box warning: serious hepatoxoticity
QT Prolongation

Question 22

Oral terbinafine

Answer 22

AE rare but severe neutropenia and noted smell and taste disturbance

Question 23

MRSA susceptible abx

Answer 23

clindamycin, bactrim, tetracycline

Question 24

Tetracyclines

Answer 24

-risk of pseudotumor cerebri alone or w/ isotretinoin, SJS/TEN, GI upset, esophagitis, vaginal candidiasis
-MCN: vestibular SE more common first few doses >F, dyspigmentation, DRESS, lupus-like syndrome, vasculitis

Question 25

Dapsone caution

Answer 25

-genetic deficiency of enzyme> G6PD (glucose-6-phosphate dehydroxygenase) causes increased hemolysis

Question 26

Dapsone monitoring

Answer 26

-CBC w/ diff, weekly x 1st month, then q2 wks x 2 mons, then q3-4 mons (hemolytic anemia predictable almost all pts, drop in hgb)
-LFTs, renal fxn & UA q3-4 mons

Question 27

Dapsone drug interactions

Answer 27

bactrim, MTX, colchicine, anticonvulsants, griseofulvin

Question 28

Hydroxychloroquine patient ed

Answer 28

-risk for blue-gray discoloration of skin
-smoking cessation
-induction or exacerbation of Pso

Question 29

Hydroxychloroquine dose/monitor

Answer 29

• ukn MOA, max dose 6.5 mg/kg/day ideal body wt (or 5mg/kg/d on actual body weight)
  -Baseline CBC w/diff, CMP, sometimes G6PD
  -Retinal tox: baseline then q 5 yrs; then 1-2 yrs; more often if high doses or elderly

Question 30

Pseudotumor cerebri

Answer 30

Headaches that start behind your eyes or in the back of the head. Blurry vision, double vision. Blackout in vision. N/V. sx worse w/ exercise.

Question 31

Spironolactone (caution)

Answer 31

-hyperkalemia: ^ risk w/ ACEs, ARBs, drospirenone, high K food/supp
sx high K: muscle cramps, weakness, muscle fatigue & paresthesias, cardiac irreg

Question 32

Acitretin contraindications

Answer 32

Pregnancy, liver or kidney impairment, chronic concomittant MTX and TCN.
Females don’t get pregnant x 3 years

Question 33

Acitretin drug interactions

Answer 33

MTX, cyclosporine, TCN & macrolide abx, ETOH, griseofulvin, rifampin, anticonvulsants, progestin only and COC

Question 34

Acitretin Serious SE

Answer 34

high TG, hypercholesterolemia, ^LFTs and pancreatitis, pseudotumor cerebri, leukopenia and agranulocystosis, skeletal hyperostosis, myopathy, hypothyroidism, DM