Immunomodulating Agents

Question 1

what is the general immunosuppressant?

Answer 1

glucocorticoid

Question 2

what are the calcineurin inhibitors?

Answer 2

cyclosporine (Neoral, Sandimmune), tacrolimus (Envarsus XR, Protopic)

Question 3

what are the mTOR inhibitors?

Answer 3

everolimus (Zortress, Afinitor), sirolimus (Rapamune)

Question 4

what are the types of immunosuppressants?

Answer 4

1) general immunosuppressant
2) calcineurin
3) mTOR inhibitor
4) TNF-alpha inhibitor
5) interleukin (IL) inhibitor

Question 5

are vaccines immunosuppressants or immunostimulants?

Answer 5

immunostimulants

Question 6

what are the goals of immunosuppressants?

Answer 6

1) limit immune-mediated damage to tissues
2) treat autoimmune diseases
3) prevent rejection of transplanted organs

Question 7

t/f: there is an increased risk for viral infections (esp upper resp infections) with immunosuppressants

Answer 7

true

Question 8

what are the indications for immunosuppressants?

Answer 8

organ transplant

chemotherapy

various autoimmune/autoinflammatory syndromes (RA, ankylosing spondylitis, Crohn’s disease, psoriasis)

Question 9

what are the TNF-alpha inhibitors?

Answer 9

Adalimumab (Humlia), infliximab (Remicode), etanercept (Enbrel)

Question 10

what are the interleukin inhibitors?

Answer 10

Anakinra (Kineret), canakinumab (Ilaris), Rinonacept (Arcalyst)

Question 11

what are the side effects of immunosuppressants?

Answer 11

GI distress, loss of appetite

increased risk of bacterial and macrophage-dependent infections (resp infections, sepsis, tuberculosis, fungal infections, etc)

increased risk of malignancies

jt pain, injection site rxn

bone marrow suppression - anemia

rash at beginning of Rx

neurotoxicity and vestibular dysfxn

insulin resistance

CV risks

catabolic effects with glucocorticoids

Question 12

a rash at the beginning of using an immunosuppressant can increase the risk of what?

Answer 12

skin cancer

Question 13

increased risk of skin cancer from a rash from immunosuppressants is especially associated with what type of med?

Answer 13

TNF inhibitors

Question 14

what is one of the most common early signs of immunosuppressants side effects?

Answer 14

neurotoxicity (weakness, headache, memory issues, etc)

Question 15

what are the CV risks associated with immunosuppressants?

Answer 15

hyperlipidemia, HTN, hyperglycemia leading to stroke risk

Question 16

do immunosuppressants or immunostimulants have lower risks associated with them?

Answer 16

immunostimulants

Question 17

what is immune globulin G (IgG)?

Answer 17

the most common immunostimulant in the body that can be given as an IV injection

Question 18

what are the indications for IgG use?

Answer 18

immunodeficiency syndromes (HIV)

Kawasaki disease

leukemia

demyelinating polyneuropathies

Question 19

what is Kawasaki disease?

Answer 19

inflammation of coronary arteries in young children

Question 20

what are some demyelinating polyneuropathies?

Answer 20

GBS, MS

Question 21

what are the side effects of IgG?

Answer 21

jt and musc pain

general malaise

GI discomfort

allergic rxn

Question 22

what is the dif bw RA and OA?

Answer 22

RA is an autoimmune disease
OA is a degenerative disease

Question 23

when RA is first diagnosed, what is the primary Rx for RA to control inflammation and prevent further boney erosions and helps manage s/s?

Answer 23

pharmacotherapy

Question 24

which pharmacotherapy is the first line of Rx bc of its anti-inflammatory properties?

Answer 24

NSAIDs

Question 25

how does acetaminophen treat RA?

Answer 25

symptomatic management bc it doesn't have anti-inflammatory effects

Question 26

what are the pharmacotherapy options for RA?

Answer 26

NSAIDs acetaminophen corticosteroids DMARDs

Question 27

are corticosteroids for RA physiologic or pharmacologic dose?

Answer 27

pharmacologic dose

Question 28

what are DMARDs (disease modifying anti-rheumatic drugs)?

Answer 28

anti-inflammatory drugs used in RA Rx to slow disease progression

Question 29

how long does it take for DMARDs to show effects?

Answer 29

weeks to months

Question 30

bc DMARDs take some time to take affect, what may be given in the meantime to manage pain?

Answer 30

aspirin or NSAIDs

Question 31

what are traditional DMARDs?

Answer 31

nonbiological nonspecific antimalarial drugs gold compunds methotrexate

Question 32

are traditional DMARDs biological or nonbiological?

Answer 32

nonbiological

Question 33

are nonbiological or biological DMARDs older generation drugs?

Answer 33

nonbiological

Question 34

what kind of DMARD is antimalarial drugs, gold compounds, and methotrexate?

Answer 34

traditional (nonbiological)

Question 35

what are biological DMARDs?

Answer 35

newer generation drugs drugs that target specific mediators in the immune system TNF inhibitors IL inhibitors

Question 36

are traditional or biological DMARDs specific to some mediators in the immune system?

Answer 36

biological DMARDs

Question 37

what are the biological DMARDs?

Answer 37

T F inhibitors IL inhibitors

Question 38

what are some common DMARDs?

Answer 38

Methotrexate (Trexall) Leflunomide (Arava) Abatacept (Orencia) Rituximab (Rituxan)

Question 39

what is the 1st and most common DMARD a pt would have?

Answer 39

Methotrexate (Trexall)

Question 40

what is methotrexate (Trexall)?

Answer 40

nonbiological DMARD immunosuppressant antimetabolites antineoplastic

Question 41

what does antineoplastic mean?

Answer 41

anti-cancer

Question 42

what is Leflunomide (Arava)?

Answer 42

nonbiological DMARD immunosuppressant antirheumatic antineoplastic

Question 43

what is Abatacept (Orencia)?

Answer 43

biological DMARD immunosuppressant

Question 44

what is Rituximab (Rituxan)?

Answer 44

biological DMARD monoclonal antibody

Question 45

what are the neurological disorders that use immunomodulatory drugs and corticosteroids?

Answer 45

MS neuromyelitis optica (Devic's disease) transverse myelitis myasthenia gravis

Question 46

what immunomodulators and corticosteroids are used for MS?

Answer 46

disease modifying drugs for initial stage corticosteroids for acute exacerbations or relapse

Question 47

what immunomodulators and corticosteroids are used for neuromyelitis optica?

Answer 47

corticosteroids mainly plasmapheresis

Question 48

what is plasmapharesis?

Answer 48

exchange of plasma hoping it will get rid of the antibodies the body has produced

Question 49

t/f: the immunomodulators and corticosteroids for transverse myelitis depend on the subtype

Answer 49

true

Question 50

what are the immunomodulators and corticosteroids for transverse myelitis?

Answer 50

corticosteroid plasmapharesis

Question 51

what are the immunomodulators and corticosteroids used for myasthenia gravis?

Answer 51

immunosuppressants more than corticosteroids plasmapheresis

Question 52

are immunosuppressants or corticosteroids more commonly used with myasthenia gravis?

Answer 52

immunosuppressants

Question 53

what are the side effects of DMARDs?

Answer 53

diarrhea rash hepatotoxicity leukopenia and anemia inc risk of infection HTN

Question 54

what are the most common symptoms of DMARD use?

Answer 54

GI symptoms

Question 55

hepatotoxicity is indicated by a rise in what?

Answer 55

liver enzymes

Question 56

t/f: hepatotoxicity is frequently seen with higher doses of DMARDs

Answer 56

true

Question 57

bc of the increased risk of infection, how long should a pt avoid live vaccines after stopping a biological DMARD?

Answer 57

at least 3 months after stopping

Question 58

what are the PT implications for DMARD use?

Answer 58

infection control CV fitness recognize and manage s/s of peripheral neuropathy (Dec sensation, numbness, tingling) , vestibular dysfxn (dizziness, balance issues) bc they increase fall risk prevent breakdown of MSK (more related to corticosteroid use) exercise modification management of chronic disease and pain

Question 59

how can we manage chronic disease and pain?

Answer 59

modalities TENS massage manual therapy low intensity aerobic exercises like swimming, Tai chi, and low stress yoga

Question 60

what are the pharmacotherapy options for OA?

Answer 60

NSAIDS (selective or non-selective) acetaminophen for pain management topical capsaicin for pain management corticosteroid disease-modifying OA drugs (DMOADs)

Question 61

are there more approved DMARDs or DMOADs?

Answer 61

DMARDs

Question 62

what are the DMOADs?

Answer 62

viscosupplementation (hyaluronic acid chicken shots) glucosamine chondroitin sulfate

Question 63

t/f: DMOADs are more for structural improvements than symptoms management

Answer 63

true

Question 64

what is hyaluronic acid?

Answer 64

lubricant and shock absorber

Question 65

where is the largest amount of hyaluronic acid?

Answer 65

in articular cartilage and synovial fluid

Question 66

what is the mechanism of action of hyaluronic acid?

Answer 66

restoring lubricating properties of synovial fluid

Question 67

t/f: hyaluronic acid may be antioxidative, anti-inflammatory, analgesic

Answer 67

true

Question 68

what are some trade names for hyaluronic acid?

Answer 68

Euflexxa, Gel-one, Hyalgon, Hylan G-F20, Monovisc, Orthovisc

Question 69

what are the side effects of hyaluronic acid?

Answer 69

muscles pain/stiffness joint pain/swelling/redness

Question 70

how long does it take for pts to see pain reduction with hyaluronic acid?

Answer 70

a few days

Question 71

how long do hyaluronic acid shots last?

Answer 71

6-12 months

Question 72

t/f: hyaluronic acid shots may be 1 or a series of shots

Answer 72

true

Question 73

t/f: common arthritis treatment may actually accelerate disease progression

Answer 73

true

Question 74

should we suggest our pts with arthritis use corticosteroid injection? why or why not?

Answer 74

no! bc it has been associated with significant progression of OA up to 2 years post-injection