Immunosuppressive and disease modifying drugs

Question 1

List the drugs classed as immunosuppressive/disease modifying

Answer 1

Corticosteroids 
Disease modifying anti rheumatic drugs
Azathioprine 
Cyclosporin 
Chlorambucil
Colchicine 
Thalidomide 
Dapsone

Question 2

Name some disease modifying anti-rheumatic drugs

Answer 2

Salazopyrine, methotrexate, penicillamine, Gold, hydroxychloroquine, chloroquine

Question 3

What are corticosteroids used for?

Answer 3

Used in the suppression of inflammatory or allergic disorders
Asthma and allergic reactions
IBD and CAH
Rheumatic disease
Inflammatory renal disease
Immunosuppression in transplantation 
Neurological disease
Cancer - lymphoma

Question 4

Where are DMARDs used?

Answer 4

Rheumatoid and sero negative arthritis
Psoriasis - methotrexate
Lupus - hydroxychloroquine
IBD - Sulfasalazine

Question 5

Where is azathioprine used?

Answer 5

Steroid sparing agent 
Rheumatoid arthritis - psoriatic agents
SLE and vasculitides - wegener's and PAN 
IBD and CAH 
Myasthenia 
Transplant patients

Question 6

Where is cyclophosphamide used?

Answer 6

Used mainly to suppress inflammation and harmful antibody production in patients with life threatening vasculitic illness
SLE
Vasculitis - wegener’s, PAN, behcet’s, Rheumatoid vasculitis

Question 7

What is cyclosporin?

Answer 7

Fungal metabolite

Active at suppressing the cell mediated T cell immune response

Question 8

Where is cyclosporin used?

Answer 8

Renal, liver, marrow, pancreas and heart transplant patients
Prophylaxis of graft vs host disease
Psoriasis and atopic dermatitis
Rheumatoid arthritis

Question 9

Where is Chlorambucil used?

Answer 9

Rheumatoid arthritis in severe disease
Vasculitides
Amyloid
Membranous nephritis

Question 10

Where is colchicine used?

Answer 10

Gout
Behcets
Serositis - pericardis, SLE, FMF

Question 11

Where is thalidomide used?

Answer 11

Behcets

SLE - especially chilblain lupus and other cutaneous manifestations of disease

Question 12

What is required before starting thalidomide treatment?

Answer 12

EMG

Effective contraception

Question 13

What are the short term risks of corticosteroid use?

Answer 13

Hypokalemia 
Fluid retention - prednisolone, dexamethasone, betamethasone
Glucose intolerance 
Mood disturbance 
Hypertension

Question 14

What are the long term risks of corticosteroid use?

Answer 14

Osteoporosis 
Diabetes and hypertension 
Accelerated atherosclerosis
 Increased risk of infection
Poor healing
Steroid dependency 
Growth retardation

Question 15

What are the risks of hydroxychloroquine and chloroquine?

Answer 15

Ocular toxicity

Question 16

What are the risks of Sulphasalazine, methotrexate, penicillamine and gold?

Answer 16

Rashes - gold and penicillamine 
GI intolerance - gold, SZP 
Renal toxicity - methotrexate 
Pulmonary fibrosis - Methotrexate 
Marrow toxicity - may occur early or late and needs regular monitoring

Question 17

What are the risks of immunosuppressive treatment?

Answer 17

Increased susceptibility to infection
Marrow suppression
Renal toxicity - cyclosporin
Haemorrhagic cystitis - cyclophosphamide
Nausea, vomiting, diarrhea - azathioprine

Question 18

Where should the first prescription of these drugs come from?

Answer 18

Provide 1st two weeks of drug from the hospital pharmacy - increases probability the patient will take the drugs and be monitored effectively

Question 19

How should high doses of corticosteroids be monitored?

Answer 19

Given in hospital - U&Es, fluid balance, BP, glucose

Question 20

How should low doses of corticosteroids be monitored?

Answer 20

BP and glucose

Question 21

How should patients on Methotrexate, SZP, Gold, Penicillamine and Azathioprine be monitored?

Answer 21

FBC, profile and urinalysis at 1,2,4 and 8 weeks then at 4 weekly intervals for 3/12

Patients who are well, with no side effects, on standard doses, can then be seen 6-10 weekly

Question 22

How should patients on Chloroquine and hydroxychloroquine be monitored?

Answer 22

Ocular examination required before treatment and at 6 months and 1 year; then yearly

G6PD screening before treatment

Question 23

How should patients on Colchicine be monitored?

Answer 23

Generally not used long term

BNF dose (1mg, then 500µg every 2-3 hours) is ridiculously high! [diarrhoea]

1g, then 500µg 4 hours later, then 500µg tds for 3-4 days, is adequate for the treatment of gout

Very poorly tolerated with misoprostol (NB arthrotec)

Question 24

How should patients on Cyclophosphamide, Chlorambucil and Cyclosporin be monitored?

Answer 24

Early monitoring as for DMARD’s - FBC, profile and urinalysis at 1,2,4 and 8 weeks

Most patients with conditions needing therapy of this type will be seen in the hospital OPD on a monthly basis, and the responsibility for haematological and biochemical monitoring is that of the specific physician seeing the patient

Question 25

How should patients on thalidomide be monitored?

Answer 25

6 monthly EMGs

Contraceptive advice