Endocrine Conditions: Systemic Steroids & Autoimmune Conditions Flashcards by Patryk Lasiuk

Cortisol replaced by giving…..

any steroids

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Aldosterone replaced by giving…..

fludrocortisone

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Fludrocortisone info

mimis aldosterone
helps keep balance of water and electrolytes

FDA approved for Addison’s disease and off-label for orthostatic hypotension

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Suppression of Hypothalamic-pituitary-adrenal axis (HPA)

systemic steroids can cause adrenal gland to stop producing cortisol due to feedback inhibition

need to be tapered off when stoping long term steroids

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Cushings syndrome

can develop when adrenal gland produces too much cortisol or too many steroids taken at higher doses

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Addison’s disease

opposite of Cushings

adrenal gland not making enough cortisol

if stop taking steroids used to help inc cortisol, can have addisonian crisis = volume depletion and hypotension = can be fatal

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Cushings Syndrome signs

fat depsits in face = moon face or buffalo hump
poor done health
diabetes
Acne
Pink-purple stretch marks and skin that bruises easily
Thin arms/legs relative to body
impaired wound healing

Women: hair growth on face + irregular or missed periods

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Cortisone: Hydrocortisone PO:IV

25mg Cortisone = 20mg Hydrocortisone

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Prednisone/Prednisolone : Methylprednisolone/Triamcinolone PO:IV conversion

5mg of either = 4mg of either

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Dexamethasone: Betamethasone PO:IV conversion

0.75mg Dexamethasone = 0.6mg Betamethasone

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Glucocorticoid contraindications

Live vaccines, serious systemic infections

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Glucocorticoid warnings

Adrenal suppression, if taking more than 14 days, taper off steroids slowly

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Glucocorticoid side effects

Short term (use < 1 month)
inc appetite, weight gain, emotional instability, insomnia

Long term: Cushing’s syndrome

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Immunosuppresion from steroids is when….

using > 2mg/kg/day or 20mg/day of prednisone or prednisone equivalent for > 2 weeks

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How to taper steroid dose

reduce dose by 10-20% every few days

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Strong immunosuppressants can increase risk of…..

reactivation of TB and Hep B/C, have to test prior to start of immunosuppressive drugs

Viruses, live vaccine have to be given before starting therapy

Lymphomas and certain cancers

infections

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RA vs OA

OA = Osteoarthritis, usually presents one side of body
RA = Rheumatoid arthritis, usually both sides, symmetrical

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RA symptoms

Joint swelling
pain
stiffness
bone deformity

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Symptomatic RA should be treated with….

methotrexate = first choice (Disease modifying antirheumatic drug)

if moderate/high disease activity after methotrexate, can add TNFi or non TNF biologic

** never use two biologic DMARDs in combo **

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RA flares

Steroids often used, should be used for lowest dose and shortest time possible

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Traditional DMARDs

Methotrexate
Hydroxychloroquine

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Methotrexate boxed warnings

Hepatotoxicity
myelosuppresion
mucositis/stomatitis
teratogenic in pregnancy

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Methotrexate CI

pregnancy
breastfeeding
alcohol use disorder
chronic liver disease

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Methotrexate side effects

N/V/D
inc LFTs
alopecia

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Methotrexate monitoring

CBC LFTs Chest Xrays Hep B/C tests

Giving folate with methotrexate

5mg weekly on day following max admin can dec hematological, GI and hepatic side effects

Hydroxychloroquine warnings

irreversible retinopathy

Hydroxychloroquine side effects

N/V/D vision changes

Hydroxychloroquine monitoring

CBC LFTs Eye exam at baseline and Q3 months **

Hydroxychloroquine risk of liver toxicity compared to MTX is....

lower, can be used as alternative if concern for liver disease

Sulfasalazine info

yellow-orange coloration of skin/urine give with folate supplement CI sulfa allergy

Leflunomide boxed warnings

dont use in pregnancy hepatotoxicity, dont use in existing liver disease

Leflunomide CI

pregnancy

Leflunamide notes

2 forms of birth control, wait for 2 years after stopping to get pregnant or use accelerate drug elimination procedure

accelerated drug elimination procedure Leflunomide

1. Cholestyramine 8grams PO TID X 11 days 2. Activate charcoal suspension 50grams PO Q12h X 11 days

JAK inhibitors

Tofacitinib (Xeljanz) Baricitinib (Olumiant) Upadacitinib (Rinvoq)

JAK inhibitors boxed warnings

serious infections ie TB, fungal, viral, bacterial etc Inc risk lymphomas and other malignancies Inc risk thrombosis

JAK inhibitors warnings

inc LFTS avoid live vaccines hematologic toxicities

Methotrexate drug interactions

dont take with alc, can inc risk of liver toxicity renal elim dec by aspirin/NSAIDs avoid w/ sulfonamides + topical tacro inc MTX/cyclosporine levels when used together

TNF inhibitors

Etanercept = Enbrel Adalimumab = Humira Infliximab = Remicade Certolizumab peg = Cimzia Golimumab = Simponi

TNF inhibitor boxed warnings

serious infections, screen for latent TB and treat Lymphomas and other malignancies

TNF inhibitor warnings

can cause demyelinating disease Hep B reactivation HF Hepatotoxicity lupus-like syndrome dont sue with other DMARDs or Live vaccines

TNF inhibitor monitoring

Prior to start = TB test, treat if needed During: signs of infection, CBCs, LFTs, TB, HBV

TNF inhibitor notes

dont freeze, keep in fridge Enbrel and Humira can be at room temp for 14 days TNFi add on, but first line in severe RA

Non TNF inhibitors

Rituximab = Rituxan Anakinra = Kineret Abatacept = Orencia Tocilizumab = Actemra Sarilumab = Kevzara

Rituxan boxed warnings

serious/fatal infusion related reactions = premed w/ tylenol+benadryl+ steroid HBV reactivation

Other non TNF inhibitor warnings

malignancies and serious infections

Enbrel dosing

once weekly

Humira dosing

every other week

Simponi dosing

monthly

Cimzia dosing

every other week after starting phase

Common symptoms of SLE

fatigue depression anorexia weight loss muscle pain malar rash = butterfly rash photosensitivity joint pain and stiffness

IgG1-lambda monoclonal antibody for SLE

Belimumab = Benlysta

Calcineurin inhibitor for SLE

Voclosporin (Lupkynis)

Lupkynis info

Boxed warning: infections, malignancies Warnings: Nephrotox, HTN, dont give with live vaccines Side effects: HTN, Diarrhea, headache, renal impairment, ab pain, UTI

treatment of MS relapse is often with....

IV steroids, usually 3-7 days IV methylpred

Glatiramer acetate (Copaxone) warnings

chest pain injection reaction

Glatiramer acetate (Copaxone) side effects

injection site reactions flushing diaphoresis dyspnea

Glatiramer acetate (Copaxone) in pregnancy

Preferred treatment if necessary

Interferon beta products

Avonex = Interferon beta-1a Betaseron = Interferon beta-1b Plegridy = Peginterferon beta-1a

Interferon beta product warnings

psychiatric disorders injection site necrosis inc LFTs, thyroid dysfunction

Interferon beta product side effects

flu-like symptoms

S1P receptor modulators

Fingolimod = Gilenya Ozanimod = Zeposia Ponesimod = Ponvory Spinonimod = Mayzent

S1P receptor modulators CI

Ozanimod = dont use with MAOi Siponimod = CYP2C9*3/*3 genotype testing

S1P receptor modulator side effects

can cause slow HR - monitor pts on Fingolimod have to be monitored for atleast 6hrs ECG inc risk of infection, screen VZV and monitor CBC malignancies, macular edema (monitor w/ eye exam), monitor LFTs

If treatment stopped with S1P receptor modulators then....

MS can get much worse

Teriflunomide (Aubagio) contraindicated in...

pregnancy

Natalizumab (Tysabri) info

for MS Boxed warning for PML and has REMS program

Alemtuzumab (Lemtrada) info

for MS Has REMS program

Raynaud's phenomenon

triggered by cold and or stress, leading to vasospasm in commonly fingers/toes. causes skin to turn white - then blue - followed by painful swelling

Celiac disease symptoms

diarrhea abdominal pain bloaing weight loss

Myasthenia Gravis treatment

Pyridostigmine warning: cholinergic effect, symptoms of excess ACh can occur

Sjögren's syndrome characterized by

dry eyes and mouth no cure

Eye drops for Dry eyes

Cyclosporine = Restasis Lifitegrast = Xiidra

Restasis info

side effects = ocular burning/stinging/redness/etc can take 3-6 months to have inc tear production

Xiidra info

Side effects = unusual taste, eye irritation

Drugs for dry mouth

OTC = sugar free gum, mouth washes, lozenges Rx = pilocarpine (salvaged) or cevimeline (Evoxac) = CI in narrow angle glaucoma and uncontrolled asthma patients

Types of Psoriasis treatment

light therapy topical meds systemic meds

Topical Psoriasis txm

Steroids Tazarotene Coal Tar products Anthralin = Zithranol CAlcipotriene Tapinarof

Retinoid for Psoriasis

Acitretin only used in severe cases Boxed warning: pregnancy and hepatotoxicity

Otezla for psoriasis info

warning: weight loss, depression, suicidal thoughts most common se are D/N/V, HA

Endocrine Conditions: Systemic Steroids & Autoimmune Conditions Flashcards

(82 cards)