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CDM 4 Exam 3 > Lecture 1 - MS/MG > Flashcards

Lecture 1 - MS/MG Flashcards

1
Q

which kind of MS is most common

A

Relapsing-remitting MS (RRMS)
like 85% of pts

can progress to secondary progressive MS

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2
Q

Kurtzke EDSS scale

A

0-10

Lower = less disability
Higher = more disability

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3
Q

Relapse/exacerbation definition

A

development of new or recurring symptoms lasting at least 24 hours and separated from previous attack by atleast 1 month

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4
Q

Treatment of acute exacerbations MS

A

Methylprednisolone
Dose: 500-1000mg IV daily
Duration: 3-7 days, improve in 3-5 days
ADE: sleep disturbance, metallic tase, BG,GI upset

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5
Q

What to give if patient refractory to steroid MS treatment?

A

Plasam exchange (PLEX) = every other day X 7 treatments
IVIG

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6
Q

“Safety; Tried and True Approach” meds

A

Interferons 1b n 1a, not much clinical difference

1a might be more potent/stable so weekly dosing n less inj site reacionts

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7
Q

Tecfidera (Dimethyl-Fumarate) MOA:

A

nicotinic acid receptor agonsit/activator

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8
Q

Tecfidera (Dimethyl-Fumarate) Dosing

A

120mg DR PO BID

inc to 240mg DR BID after 7 days
dont crush, swallow whole

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9
Q

How to decrease flushing with Tecfidera (Dimethyl-Fumarate)

A

Take with food
consider non-EC ASA of < 325mg 30min prior

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10
Q

Tecfidera (Dimethyl-Fumarate) Adverse effects

A

Lympgocytopenia
LFTs
Flushing
GI after 1 month
Anaphylaxis
Angioedemia

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11
Q

Interferon B-1b Brand names

A

Betaseron
Extavia

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12
Q

Interferon B-1b dose

A

titrate to 250mcg
Given SC every other day

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13
Q

Interferon B-1b storage

A

doesnt req fridge

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14
Q

Avonex info

A

Interferon B-1a

Dose:30mcg IM weekly
Storage: Fridge or RT 7 days

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15
Q

Rebif info

A

Interferon B-1a

Dose:22 or 44mcg SQ 3 times weekly
Storage: Fridge or RT 30 days

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16
Q

Plegridy info

A

Interferon B-1a

Dose: 125 mcg SQ every 14 days
Storage: Fridge, RT 30 day, protect from light

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17
Q

Interferon warnings

A

Liver dysfunction
Worsening Depression

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18
Q

Interferon adverse effects

A

Inj site redness
swelling
Flu-like symptoms

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19
Q

Interferon monitoring

A

BL: Blood count, Platelets, LFTs

continue at 1 month, Q3 for 1 yr, then Q6

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20
Q

Interferon counseling

A

Body temp at injection

Rotate inj site, apply cold pack before/after, hydrocortisone cream

Flu-like symptoms = Last ~24hrs, give APAP or NSAIDs before/after inj

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21
Q

Glatiramer Acetate (Copaxone) Dose

A

20mg SQ daily or 40mg SQ 3 times weekly (start 1-2 days after 20mg dose)

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22
Q

Glatiramer Acetate (Copaxone) Adverse effects

A

10% transient chest tightness
Flushness n dyspnea

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23
Q

Glatiramer Acetate (Copaxone) Storage

A

Fridge
RT for 30 day

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24
Q

Glatiramer Acetate (Copaxone) place in therapy

A

1st or 2nd line depending on pt factors

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25
Q

Tecfidera (Dimethyl-Fumarate) Monitoring

A

screen TB
CBC
D/c therapy if lymphocyte count < 0.5 X 10^9 > 6 month
BL LFTs, D/c if liver injury suspected

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26
Q

Monomethyl-Fumarate (Bafiertam) Dosing

A

95mg DR PO BID for 7 days, then 2 caps (190mg) DR BID
swallow whole, dont crush

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27
Q

Monomethyl-Fumarate (Bafiertam) Adverse effects

A

Lympgocytopenia
LFTs
Flushing
GI after 1 month
Anaphylaxis
Angioedemia

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28
Q

How to decrease flushing with Monomethyl-Fumarate (Bafiertam)?

A

Take with food
consider non-EC ASA of < 325mg 30min prior

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29
Q

Diroximel-Fumarate (Vumerity) Dosing

A

231mg DR PO BID for 7 days, then inc to 2 cap (462mg) DR PO BID

Avoid w/ high-fat, high calories meal/snack, alc

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30
Q

Diroximel-Fumarate (Vumerity) Adverse effects

A

Less chance of GI (1% vs 5% Tecfidera)

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31
Q

Teriflunomide (Aubagio) Dosing

A

7-14mg PO QD

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32
Q

Teriflunomide (Aubagio) Black Box warning

A

Hepatotoxicity
Pregnancy/women use reliable Birth control

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33
Q

Teriflunomide (Aubagio) DI

A

Warfarin = dec INR
Avoid Live vaccines
Rosuvastatin max dose = 10mg

34
Q

Teriflunomide (Aubagio) Adverse effects

A

shit load

35
Q

Teriflunomide (Aubagio) Accelerated elim procedure

A

Cholestyramine 8gram Q8H X 11 days or activated charcoal 50gram Q12 X 11 days

days dont need to be consecutive

36
Q

Fingolimod (Gilenya) Dose

A

0.5mg QD PO > 40kg
0.25mg QD PO < 40kg

37
Q

Fingolimod (Gilenya) Adverse effects

A

Headache
infections
diarrhea
QTc prolong*
Macular edema*
HTN*
cough
LFT elevation

38
Q

Fingolimod (Gilenya) Monitoring

A

observe 6hrs after 1st dose for Bradycardia w/ hourly HR/BP

inc risk of major congenital malformations

women on BC during and 2 months after med, same rules for live vaccines

39
Q

Fingolimod (Gilenya) Safety Concerns

A

Rare cases of PRES

CI in pts w/ preexisting Heart conditions, stroke, or on class Ia or III anti arrhythmic meds

40
Q

Siponimod (Mayzent) dosing depends on…..

A

CYP1C9 Genotype

41
Q

Siponimod (Mayzent) Dosing if 1/3 or 2/3 alleles….

A

0.25mg daily on Day 1+2, 0.5mg Day 3, 0.75mg Day 4, and 1mg after

other alleles, dosing inc to 2mg at end of titration

42
Q

Siponimod (Mayzent) place in therapy

A

Approved for RRMS, active SPMS and clinically isolated syndrome

43
Q

Siponimod (Mayzent) Adverse effects

A

pretty much same as Fingolimod (Gilenya)

44
Q

Siponimod (Mayzent), if titration dose missed then….

A

if more than 24hrs, treatment needs to be reinitiated with Day 1 of the titration regimen

45
Q

Which CYP2C9 Genotype is Siponimod (Mayzent) CI in?

A

CYP2C9 3/3

46
Q

Siponimod (Mayzent) Considerations

A

also avoid live vaccines during n 1 month after
monitor if history of bradycardia for 1st dose
women also need to be on BC during and 10 days after

47
Q

Siponimod (Mayzent) Safety concerns

A

Rare PRES
Rare PML
CI w/ Heart conditions, Stroke, TIA

48
Q

Ozanimod (Zeposia) Dosing

A

Day 1-4 = 0.23mg PO QD
Day 5-7 = 0.46mg PO QD
Day 8+ = 0.92mg PO QD

49
Q

Ozanimod (Zeposia) ADE

A

Upper Resp tract infection
Orthostatin HTN

50
Q

Ozanimod (Zeposia) CI

A

MI, unstable angina, stroke, TIA, HF hospitalization, C3-4 HF in last 6 months, untreated severe sleep apnea, dont use with MAOI

51
Q

Ozanimod (Zeposia) DI

A

MAOI
SSRI, SNRIs, TCA, opioids
Strong CYP2C8 inducers/inhibitors

52
Q

Ponesimod (Ponvory) Dosing

A

starts at 2mg QD X 2 days, day 15 is 20mg QD maintenance dose

Monitoring 1st dose if Hr < 55BPM

53
Q

Cladribine (Mavenclad) dosing

A

Cumulative dose of 3.5mg/kg PO and divided into 2 txm courses (1.75mg/kg each)
Each txm course is divided into 2 txm cycles

Dont admin cladribine during following 2 yrs after therapy
** Not 1st line, for those who cant tolerate others**

54
Q

What drugs to avoid with Cladribine (Mavenclad)

A

avoid antiviral or antiretroviral drugs ( Lamivudine, ribavirin, zidovudine)

separate other oral drugs by atleast 3hrs during the 4-5 day treatment cycles

55
Q

Cladribine (Mavenclad) Black box warning

A

May inc malignancy, CI if currently have
CI in preg women and men/women not on effective contraceptives

56
Q

Cladribine (Mavenclad) Monitoring

A

CBC/LFT
Cancer screen
Preg test
Latent infections
MRI to exclude PML

< 200 Lymphocyte count at months 2/6…herpes prophylaxis considered if < 200

57
Q

Kesimpta (ofatumumab) dosing

A

20mg SC injection weekly for 3 doses, then 20mg Q monthly

58
Q

Kesimpta (ofatumumab) CI

A

Active HBV infection
careful if active infection, recent vaccine admin

59
Q

Alemtuzumab (Lemtrada) Dosing

A

IV infusion
12mg IV QD X 5 days (60mg total)
12mg QV X 3 days 12months after initial (36mg)

60
Q

Alemtuzumab (Lemtrada) place in therapy

A

pts w/ relapsing form of MS or inadequate response to 2+ MS therapies

61
Q

Alemtuzumab (Lemtrada) monitoring

A

Has REMS program

Monitor: Infusion reaction, CBC/Scr/UA QM n 48M after

62
Q

Alemtuzumab (Lemtrada) HSV prophylaxis

A

acyclovir 200mg BID > 28days after last infusion or until CD4 count > 200 (whichever is last)

63
Q

Alemtuzumab (Lemtrada) PCP prophylaxis

A

Bactrim SS QD, during txm n several weeks after

64
Q

Ocrelizumab (Ocrevus) dosing

A

300mg IV X 1, then 300mg IV X 1 2 weeks later (max 180ml/hr, >2.5hr infusion) then 600mg IV every 6 months (max 200ml/hr, >3.5hr infusion)

premed and monitor 1hr post infusion

65
Q

Natalizumab (Tysabri) dosing

A

300mg IV q4 weeks

66
Q

Natalizumab (Tysabri) info

A

REMS
Black box for PML

monitor infections, LFTs

67
Q

screening for JC virus is useful in….

A

screening for PML

68
Q

Ublituzimab (Briumvi) Dose

A

IV infusion
1st dose = 150mg IV over 4hrs
2nd dose = 450mg IV over 1hr, 2 weeks after first
Later doses = 450mg over 1hr 24weeks after 1st infusion and every 24 weeks after

premedicate

69
Q

Ublituzimab (Briumvi) info

A

dec vaccine efficacy
screen for Hep B

70
Q

Dalfampridine (Ampyra) can help…

A

inc walking speed in pts by 25%…clinically meaningful?

71
Q

Dalfampridine (Ampyra) dosing

A

10mg BID ~ 12hr apart

72
Q

Dalfampridine (Ampyra) CI

A

Seizue history
Crcl < 50, 51-80 = inc seizure risk

73
Q

Dextromethorphan & Quinidine (Nuedexta) dosing

A

Days 1-7 = 1 QAM
Days 8+ = 1 BID (AM/PM)

dont double if missed, take ~12hr apart

used for random laughing/crying/etc (Pseudobulbar effect)

74
Q

Dextromethorphan & Quinidine (Nuedexta) SE + DDI + CI

A

Digoxin = monitor lvls
Cardiac abnormalities

75
Q

Class 1 vs 5 for MS

A

1 = less severe
5 = most severe

76
Q

Pyridostigmine (Mestinon) Info

A

1st line MS
Dosing highly individualized
PO = bunch of forms, IV/IM = 2mg Q2-3hr or 1/30th PO dose in crisis

77
Q

Pyridostigmine (Mestinon) Side effects

A

Salivaton
urinary incontinence
diarrhea
sweating

can manage with Glycopyrrolate or Hyoscyamine TID

78
Q

Pyridostigmine (Mestinon) caution

A

start low n titrate

79
Q

Meds that can worsen or unmask MG

A

Fluoroquinolones
Macrolides
Aminoglycosides
Beta-blockers
Statins

80
Q

Immunomodulating Therapies

A

add after AChE inhibitor
Azatthioprine = 1st choice, delayed onset of action….start with red for faster effect

81
Q

Immunomodulating Therapies to avoid

A

CI to Glucocorticoids
Liver disease = avoid Azathioprine
Renal disease = avoid cyclosporine
Leukopenia = avoid azathioprine & mycophenolate

CDM 4 Exam 3 (11 decks)

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