Immunotherapeutics

Question 1

what actions do corticosteroids have?

Answer 1

glucocorticoid and mineralocorticoid actions

Question 2

how does the dose of dexamethasone compare to that of prednisone?

Answer 2

dex 7x pred

Question 3

what is the anti-inflammatory dose of prednisone?

Answer 3

0.5-1 mg/kg

Question 4

what is the physiologic dose of prednisone?

Answer 4

0.2 mg/kg

Question 5

what is the mechanism of action of cyclosporin?

Answer 5

inhibits calcineurin which reduces cytokines needed for T cell function

Question 6

what is bioavailability like of cyclosporin?

Answer 6

variable: need to do therapeutic drug monitoring for life-threatening states like transplantation

Question 7

what is the mechanism of action of mycophenolate?

Answer 7

inhibits enzyme needed for purine synthesis

Question 8

what is the mechanism of action of azathioprine?

Answer 8

antimetabolite purine antagonist

Question 9

what are the adverse effects of chlorambucil?

Answer 9

myelosuppression
gastrointestinal upset

Question 10

in whom is chlorambucil more commonly used in?

Answer 10

cats: blood disorders and IBD, small cell
dogs: PLE

Question 11

what are the pros of using two drugs?

Answer 11

potentially more rapid/complete immunosuppression
may be able to taper steroid faster

Question 12

what are the adverse effects of mycophenolate?

Answer 12

hemorrhagic diarrhea
anorexia

Question 13

what drugs are often used as second drugs in dogs?

Answer 13

azathioprine
mycophenolate
cyclosporine

Question 14

is there evidence to suggest that one drug is better for a second drug than others?

Answer 14

no

Question 15

which drugs are used as second drugs in cats?

Answer 15

usually cyclosporine or chlorambucil

Question 16

what second drug cannot be used in cats?

Answer 16

azathioprine

Question 17

which second drug has the fastest speed of onset?

Answer 17

cyclosporine

Question 18

how do the costs of cyclosporine, mycophenolate, and azathioprine compare?

Answer 18

cyclosporine»mycophenolate~azathioprine

Question 19

which second drug needs to be monitored with CBC and chem?

Answer 19

azathioprine
mycophenolate sometimes CBC

Question 20

how long are you treating with immunosuppressive tapering?

Answer 20

months

Question 21

do life-threatening diseases need longer treatment than non-life-threatening diseases?

Answer 21

not always

Question 22

how long does clinical remission of a systemic immune-mediated disease take?

Answer 22

usually 1-4 weeks

Question 23

if an animal is on two drugs, what do you taper first?

Answer 23

prednisone usually

Question 24

how do you taper?

Answer 24

~25% every 2-4 weeks

Question 25

how do you taper the second drug?

Answer 25

some taper following a similar schedule as for prednisone

Question 26

what should you check before commencing tapering and every time you reduce the dose?

Answer 26

parameter of interest: platelets, red blood cells

Question 27

what does the total treatment time depend on?

Answer 27

the disease

Question 28

what is the treatment time for many conditions?

Answer 28

4-8 months timeframe

Question 29

why should you not continue drugs at full doses forever without attempting a taper?

Answer 29

prednisone side effects can lead to euthanasia excessive immunosuppression increases the risk for infections and malignancies

Question 30

which secondary agent is used in horses?

Answer 30

azathioprine mostly

Question 31

what is the immunosuppressive dose of pred?

Answer 31

2 mg/kg

Question 32

what are some side effects of glucocorticoids?

Answer 32

pu/pd alopecia thin skin

Question 33

what are the adverse effects of cyclosporin?

Answer 33

GI upset gingival hyperplasia weird infections

Question 34

what are the adverse effects of azathioprine?

Answer 34

hepatotoxicity myelosuppression

Question 35

what are the adverse effects of mycophenolate?

Answer 35

hemorrhagic diarrhea anorexia

Question 36

what makes using chlorambucil difficult?

Answer 36

expensive need to compound risks to household must monitor CBC

Question 37

what are the cons of using two drugs?

Answer 37

increased cost may need more monitoring potential for side effects from second drug may be more immunosuppressed than necessary no proof superior response/outcome than just using pred

Question 38

what is usually prescribed for perianal fistulas?

Answer 38

calcineurin inhibitor

Question 39

how does GI tolerance compare for the three second drugs?

Answer 39

azathioprine>mycophenolate>cyclosporine

Question 40

how can you taper pred if a second drug is used in IMHA?

Answer 40

25-33% every 3 weeks or 25% every 2 weeks can taper 25-50%

Question 41

what diseases are likely lifelong treatment?

Answer 41

atopic dermatitis IBD

Question 42

how long should you treat IMHA?

Answer 42

glucocorticoid: 3-6 months all immunosuppressive therapy: 4-8 months

Question 43

what should you do if there is a relapse?

Answer 43

confirm relapse assess for trigger or missed diagnosis add second drug if relapse was not during taper if during taper: return to previous dose/effective dose double time to initial taper and between subsequent tapers

Question 44

what secondary agents are used in equine?

Answer 44

azathioprine cyclophosphamide local cyclosporine