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IPT: MS > More Block 2 > Flashcards

More Block 2 Flashcards

(103 cards)

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1
Q

What kind of disease is SLE and who does it occur most often in?

A

Chronic autoimmune disease

Women, teenage to early 50s, more common in AA or hispanics

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2
Q

What causes SLE?

A

Genetic factors (HLA-DR2/3) and environmental factors (Ebstein-Barr virus, hydrazine from smoking, estrogen, rx, UV light)

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3
Q

Presentation of SLE?

A

Multi organ involvement + SLE flare

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4
Q

How is lupus nephritis classified?

A

Class III = focal (<50% glomeruli involvement)

Class IV = diffuse (≥50% glomeruli involvement)

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5
Q

What can antiphospholipid syndrome cause?

A

Increased risk of VTE, thrombosis, and fetal loss

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6
Q

How is antiphospholipid syndrome diagnosed?

A

At least 1 clinical:

  • thrombosis
  • 1+ unexplained death of fetus
  • 3+ unexplained miscarriages before 10th week of gestation

At least 1 lab criteria, intermediate or high titers of:

  • IgG or IgM
  • Lupus anticoagulant antibodies
  • Anti Beta-2 glycoprotein I antibodies

All lab tests involve 2 tests 3 months apart

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7
Q

What lab tests are involved for SLE?

A

ANA and APA

CBC w/ differential

SCr

Urinalysis w/ microscopy

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8
Q

Nonpharmacologic therapy for SLE?

A
  • smoking cessation
  • sun protection
  • pneumococcal, influenza, hep B (just dont give live to pts receiving immunotherapy)
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9
Q

Uses of ASA? Considerations?

A

Low dose for antiphospholipid syndrome

Reye’s syndrome

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10
Q

Uses of Steroids? Considerations?

A

Locally for skin manifestation (low potency for areas like the face)

If given systemically, use calcium/vit.d/bisphosphonates for osteoporosis prevention

Caution with live vaccines

Increased % of infections

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11
Q

Use of Hydroxychloroquine? Considerations?

A

All pt with lupus (can reduce clotting)

Risk include retinal toxicity

Dont exceed 5mg/kg/day or 400mg daily

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12
Q

Use of methotrexate? Considerations?

A

Given once weekly, max of 20mg/week

Dose adjustments for renal/hepatic impairment

AVOID in pregnancy

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13
Q

Use of azathioprine? Consideration?

A

Used as MAINTENANCE therapy for nephritis only

Lower dose if TPMT deficient

DDI w/ allopurinol and febuxostat

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14
Q

Use of mycophenolate? Consideration?

A

Used as both MAINTENANCE + INDUCTION therapy for nephritis

AVOID in pregnancy

Highly protein bound

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15
Q

Use of cyclophosphamide? Consideration?

A

Used as INDUCTION therapy only for nephritis

AVOID in pregnancy

Infertility issue in women and men

Can cause hemorrhagic cystitis and bladder cancer

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16
Q

Belimumab MOA?

A

Recombinant antibody that promotes B cell apoptosis by binding to BLyS

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17
Q

Use of Belimumab? Consideration?

A

ADJUNCT therapy with positive SLE

Dont give with live vaccines within 30 days, dont give with other biologics or cyclophosphamide

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18
Q

Use of Rituximab? Consideration?

A

Salvage therapy for both SLE and lupus nephritis

Premedicate to prevent infusion and hypersensitivity reactions

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19
Q

Primary prophylaxis for antiphospholipid syndrome? Secondary prophylaxis? Duration?

A

HoCQ or low dose ASA

With DEFINITE APS and first event, treat with warfarin

If first VTE event, low risk for APS and known factors, 3-6 months

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20
Q

What patient population is affected by drug-induced lupus?

A

Caucasian older patients

Except in minocycline, then its younger females patients

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21
Q

How is drug-induced lupus presented and what are some lab findings?

A

Systemic symptoms

Positive ANA and histone antibodies

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22
Q

What are the common drugs to cause drug-induced lupus?

A

Procainamide
Isoniazid
Hydralazine

Minocycline
Methyldopa

Quinidine
TNF alpha inhibitors (etanercept, infliximab, and adalimumab)

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23
Q

What kind of symptoms can procainamide cause? RF?

A

Usually MSK sx

RF = slow acetylators

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24
Q

What kind of symptoms can hydralazine cause? RF?

A

Usually MSK sx with cases of glomerulonephritis

RF = >200mg/day or cumulative dose of 100g

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25
What kind of symptoms can TNF alpha inhibitors cause? RF?
Usually MSK or cutaneous symptoms
26
What kind of symptoms can minocycline? RF?
Usually MSK or hepatic symptoms RF = younger patients
27
What are some medications that should be held before surgery?
Antithrombotic therapy Cardiac meds Diabetic meds Herbal meds
28
What are the high thromboembolic risk patients?
Mech. mitral valve or valve prosthesis CHADSVASC score 7-9 Stroke or TIA within 3 months Rheumatic valvular heart disease VTE within 3 months Severe thrombophilia
29
What are the moderate thromboembolic risk patients?
Aortic valve replacement and one of the following: A. fib, diabetes, CHF, >75yo CHADSVASC score 4-6 VTE within 3-12 months Non severe thrombophilia Active cancer
30
What are the low thromboembolic risk patients?
Aortic valve replacement w/o RF CHADSVASC score of 0-3 VTE >12 months ago with no RF
31
What operations are considered high surgical bleed risk?
Orthopedic Low = dental, endoscopy w/o biopsy, dermatologic, cataract surgery
32
When do you d/c warfarin before surgery?
5 days prior
33
When do you check INR if pt was on warfarin before surgery? What can you do if elevated?
1 day prior Give low dose PO vit. K for INR >1.5
34
When can you resume warfarin after surgery?
12-24 hrs after surgery
35
If pt is going through a low bleed risk procedure, when can you stop warfarin?
2-3 days prior (or give warfarin as is with prohemostatic agent)
36
What is the advantage of bridging with LMWH or heparin products?
You can stop 4-6 hours (UFH) or 24hrs (LMWH) before surgery vs 5 days prior with warfarin alone
37
When can you continue LMWH therapy after high bleed risk surgery?
2-3 days after surgery
38
How long should you hold theses DOACs in minor surgery (good renal function)? Dabigatran Rivaroxaban Apixaban Edoxaban
All 1 day prior to surgery
39
How long should you hold theses DOACs in major surgery (good renal function)? Dabigatran Rivaroxaban Apixaban Edoxaban
All 2 days prior to surgery, except dabigatran is 2-4 days prior
40
How long should you hold theses DOACs in minor surgery (CrCl<50)? Dabigatran Rivaroxaban Apixaban Edoxaban
Dabigatran = at least 2 days prior Rivaroxaban = 1-2 days Apixaban = 1-2 days Edoxaban = n/a
41
How long should you hold theses DOACs in major surgery (CrCl<50)? Dabigatran Rivaroxaban Apixaban Edoxaban
Dabigatran = 4 days Rivaroxaban = 3-4 days Apixaban = 3-4 days Edoxaban = n/a
42
When should someone with aspirin continue using their dose when undergoing some operation?
If using for secondary CV disease prevention or on low bleed risk surgery Moderate to high risk for CV and require non-cardiac surgery Undergoing CABG. If they are on dual antiplatelet therapy, stop clopidogrel/prasugrel 5 days prior
43
When should someone with aspirin stop taking their dose when undergoing some operation?
If they are low risk for CV event, stop it 7-10 days prior
44
When should surgery be deferred if they are on aspirin?
If they have a coronary stent on dual antiplatelet therapy (at least 6 wks on bare metal stent or 6 months after drug eluting)
45
When should someone on P2Y12 inhibitors hold their dose before surgery?Cilostazol?
5-10 days prior for clopidogrel or prasugrel 5 days prior for ticagrelor 2-3 days prior for cilostazol
46
What is virchow's triad?
Hypercoagulability Blood flow stasis Vessel wall injury
47
Which surgeries should include VTE prophylaxis?
Major orthopedic surgery or anyone with fracture of pelvis, hip, or long bone
48
Those with total hip or knee arthroplasty should receive which VTE prophylaxis?
Receive aspirin or anticoagulant therapy DOACs>LMWH>Warfarin when anticoagulation is needed LMWH>UFH
49
Those with hip fracture repair should receive which VTE prophylaxis?
LMWH or UFH
50
VTE prophylaxis, Rivaroxaban dosing?
10mg QD within 6-10 hrs after surgery for 10-14 days (maybe up to 35 days) Avoid if CrCl<30
51
VTE prophylaxis, Apixaban dosing?
2.5mg BID within 12-24hrs after surgery for 10-14 days (maybe up to 35 days)
52
VTE prophylaxis, Dabigatran dosing?
110mg once within 1-4hrs after surgery for 10-14 days. MD = 220 QD (maybe up to 35 days) Avoid if CrCl<30
53
VTE prophylaxis, ASA dosing?
After 5 days of anticoagulation, initiate 81mg QD
54
VTE prophylaxis, LMWH (Lovenox) dosing?
40mg QD or 30mg q12hrs. You can start 12hrs after surgery for 10-14 days (maybe up to 35 days) Renal dosing = 30mg QD
55
VTE prophylaxis, UFH dosing?
5000u every 8-12hrs within 12 hrs of surgery for 10-14 days (maybe up to 35 days)
56
VTE prophylaxis, Fondaparinux dosing?
≥50kg: 2.5 QD within 6-8hrs after surgery for 10-14 days (maybe up to 35 days) Avoid if CrCl<30
57
RF for infection prevention?
Diabetics, Malnutrition, inflammatory arthritis, MRSA colonization, skin infection/chronic UTIs
58
When are prophylactic ABx given and d/c after surgery? Which ABx are they?
Given 1 hr prior D/c within 24 hrs afterwards (unless cardiac, then 48hrs) Cefazolin 2g (3g if ≥120kg) or clinda or vanco if allergic to B-lactam
59
What is rhabdomyolysis?
Muscle pain and/or weakness with elevations of CK >10ULN with evidence of AKI A kind of myopathy
60
What is creatine kinase?
Intracellular enzyme that is released due to cell membrane damage Testing for them is highly sensitive, but is not very specific
61
What is a general CK range what can cause it to rise?
<300IU/L in adults Thyroid, muscular dystrophy, dehydration, MI
62
Normal serum levels of Myoglobin? What are some symptoms of high levels?
>85ng/mL suggest muscle injury Tea-colored urine
63
What time frame does myopathy occur when it is drug-induced?
6 months
64
What are the most common drugs that cause myopathies?
Statins, Fibrates, steroids, antiretrovirals, daptomycin
65
What causes necrotizing myopathy?
Statins, fibrates, and alcohol
66
Which statins have a greater risk for myopathy?
Simvastatin, Atorvastatin, Lovastatin due to their lipophilic profile Simvastatin has many interaction to lower its risks
67
(Fenofibrate/Gemfibrozil) has more risk for myopathies
Gemfibrozil
68
What causes mitochondrial myopathy?
Zidovudine, ipecac
69
What causes inflammatory myopathy?
D-penicillamine and PPI
70
What causes painless myopathies?
Diuretics, laxatives, and corticosteroids
71
Which electrolyte deficiencies causes myopathies?
Low K, Low phosphate, high magnesium
72
Which kind of myopathy may CK not be elevated?
Painless myopathy due to corticosteroids
73
Clinical presentation of rhabdomyolysis?
Tea colored urine Weakness Muscle pain
74
Other labs to check due to rhabdomylosis?
Hyperkalemia and hypocalcemia Treat hypocalcemia if symptomatic
75
Causes of rhabdomylosis?
Trauma (crush syndrome), strenuous exercise, fibrates, statins, alcohol, cocaine
76
Rhabdomyolysis management?
Fluid resuscitation ASAP initially at 400ml/hr then 2-3ml/kg/hr *avoid diuretics*
77
What is myasthenia gravis?
Neuromuscular junction disorder that displays weakness and fatigue of skeletal muscles caused by AChR antibodies
78
Pyridostigmine MOA and AE?
Blocks acetylcholinesterase and increases ACh in synapse AE = bradycardia, increased salivation, twitching
79
Pyridostigmine pearls?
Caution in glaucoma, CV disease or respiratory disease Works within 15-30 min
80
Prednisone pearls?
Used if pt did not meet tx goal after using pyridostigmine Treat for 1 month then slowly taper from 10mg a month
81
When should immunosuppression be used in MG?
If steroid AE develop, is inadequate, sx relapse, or if refused/CI
82
Azathioprine MOA and AE?
Blocks purine synthesis AE = leukopenia, thrombocytopenia, liver issues, increased infection
83
Azathioprine pearls?
Monotherapy or with steroid and/or pyridostigmine Can take up to a year to work BBW of chronic suppression leading to malignancy Warning for TPMT deficiency Avoid allopurinol
84
Cyclosporine MOA and AE?
Blocks production/release of IL-2 AE = Liver damage, infection risk, HTN, hirsutism, increased TG
85
Cyclosporine pearls?
Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine May take a few months to work BBW of increased risk of infection, HTN, malignancy, and nephrotoxicity Grapefruit juice increases concentration Therapeutic range 150-200
86
Tacrolimus MOA and AE?
Calcineurin inhibitor; blocks T cell activation AE = HTN, high potassium
87
Tacrolimus pearls?
Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine Takes up to 12 months to work BBW of risk of infection and malignancy Therapeutic range 5-15
88
Mycophenolate mofetil MOA and AE?
Blocks purine synthesis HTN/Hypotension, tachycardia, hypercholesterolemia
89
Mycophenolate mofetil pearls?
Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine Takes up to 12 months BBW of increased risk of infection, lymphoma, skin malignancy, pregnancy loss in first trimester
90
Eculizumab MOA and AE?
Binds to complement protein 5 HTN/hypotension, tachycardia, hypokalemia, UTI
91
Eculizumab pearls?
For generalized MG in refractory pt BBW of N. meningitidis (give vaccine 2 weeks prior)
92
Rituximab MOA and AE?
Binds to CD20 on B cells Flushing, night sweats, HTN
93
Rituximab pearls?
For severe refractory MG Considered as an early tx option in those w/ MuSK antibody positive MG who failed initial immunotherapy BBW of Hep B reactivation
94
What are the sx of Myasthenia crisis and how do you treat it?
Sx = difficulty breathing Tx = plasmapheresis or IVIg
95
When should someone not take plasmapheresis or IVIg?
Plasmapheresis = sepsis IVIg = hypercoagulable state, renal failure
96
What meds can exacerbate MG?
BB ABx Botulinum toxin Magnesium ...caines Penicillamine Quinine derivates
97
MG presents in whom?
Women <40 or Men <50
98
What is GBS? and who does it affect?
Immune system attacks PNS particularly the brain and spinal cord; acute inflammatory demyelinating polyneuropathy is the most common form Affects more men than women and in older adults, but can occur at any age
99
Pathophys of GBS?
Damage to myelin sheath of peripheral nerves via MAC attack on Schwann cells Cause is unknown but most cases occur after acute respiratory or GI infection. Could be from vaccinations too
100
What labs could be collected for GBS?
Elevated CSF Decreased WBC
101
How is GBS diagnosed?
Symmetrical weakness, usually starting in legs (sometimes pain, numbness, tingles occur around the weakness time)
102
GBS treatment?
Within 2 weeks Plasmapheresis or IVIg
103
Which vaccines are CI for GBS?
Within 6 weeks of GBS = flu and Tdap/Td

IPT: MS (3 decks)

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