Systemic Steroids and Autoimmune

Question 1

Steroids most common for anti-inflammatory

Answer 1

Hydrocortisone, Cortisone, Prednisone

Question 2

Steroids used to replace aldosterone

Answer 2

Fludrocortisone

Question 3

Why chronic steroids need to be tapered

Answer 3

Adrenal gland stops producing cortisol through feedback inhibition → suppression of HPA → taper to allow endogenous cortisol production to resume

Question 4

What is Cushings

Answer 4

Too much cortisol → high doses of exogenous steroids

Question 5

What is Addisions

Answer 5

Sudden stop of exogenous cortisol → adrenal gland is not make enough cortisol

Question 6

Long term effect of steroids

Answer 6

Psychiatric changes
Glaucoma, cataracts
Buffalo hump
Acne, moon face
Striae
Diabetes
Growth retardation
Hirsuism, irregular menses
Impaired wound healing
Osteoporsis

Question 7

How to reduce the effects of systemic steroids

Answer 7

1. Use every other day dosing
2. Intra-articular injections for joints
3. Steroids with low GI absorption
4. Lowest effective dose for shortest amount of time

Question 8

Shortest acting CS

Answer 8

Cortisone > hydrocortisone

Question 9

Immediate acting CS

Answer 9

Prednisone > Presnisolone > Methylprednisolone > Triamcinolone

Question 10

Long acting CS

Answer 10

Dexamethasone > Betamethasone

Question 11

Dexamethasone

Answer 11

Decadron

Question 12

Hydrocortisone

Answer 12

Solu-Cortef

Question 13

Methylprednisolone

Answer 13

Solu-medrol, Medrol

Question 14

Prednisone

Answer 14

Deltasone

Question 15

Prednisolon

Answer 15

Millipede, Orapred

Question 16

Triamcinolone

Answer 16

Kenalog

Question 17

How to take CS

Answer 17

If QD, take between 7-8am to mimic natural cortisol release

Take with food

Question 18

Prodrug of Cortisol

Answer 18

Cortisone

Question 19

Prodrug of prednisolone

Answer 19

Prednisone

Question 20

How long does a steroid treatment need to be to require tapering

Answer 20

> 14 days

Question 21

Short term ADRs of steroids

Answer 21

Fluid retention, insomnia, emotional instability, weight gain, ↑ appetite, ↑ BP and BG, GI upset (take with food)

Question 22

Nonspecific lab test to detect inflammation

Answer 22

ESR, CRP, RF, ANA

Question 23

Strong immunosuppressant can ↑ the risk of what conditions

Answer 23

1. Reactivation of hep B and C
2. Infection
3. No live vaccines
4. Lymphomas and skin cancers

Question 24

What are the classic sx of RA

Answer 24

Joint swelling
Pain
Stiffness
Bone deformity

Question 25

How do you contrast RA from OA

Answer 25

Bilateral, symmetrical inflammation with pain Worse at rest → morning stiffness Presence of ACPA and RF

Question 26

What is the preferred treatment for RA

Answer 26

DMARD (never use 2 DMARDs in combo) → Methotrexate is the preferred initial therapy

Question 27

Methotrexate

Answer 27

Trexall

Question 28

Non-biologic DMARDs indicated for RA

Answer 28

Methotrexate Hydrochloroquine Sulfasalazine Leflunamide Jak inhibitors

Question 29

Hydrochloroquine

Answer 29

Plaquinel

Question 30

MOA of Trexall

Answer 30

Inhibits DHF reductase → inhibiting folate

Question 31

Dosing of methrotrexate for RA

Answer 31

7.5-20 mg QW (IM, SC, PO) Never dose QD

Question 32

BBW of Trexall

Answer 32

Hepatotoxicity, myelosuprression, mucositis/stomatitis, pregnancy

Question 33

What to monitor for Trexall

Answer 33

CBC, LFT, Chest X ry, Hep B and C

Question 34

How to mitigate some ADRs of methotrexate?

Answer 34

Supplement folate (5 mg PO QW on the following MTX)

Question 35

ADR of Plaquenil

Answer 35

Irreversible retinopathy, QTc prolongation, vision changes

Question 36

How often to get an eye exam while on Plaquenil

Answer 36

Q3M

Question 37

use of Plaquenil over trexall

Answer 37

Less hepatoxiticy

Question 38

CI of sulfasalazien

Answer 38

Salicylate and sulfa allergies

Question 39

Counseling of Sulfasalazine

Answer 39

Take with 8 oz of water to prevent crystalluria Yellow-orange urine

Question 40

MOA of leflunamide

Answer 40

Inhibits pyrimidine synthesis → anti proliferative and anti-inflammatory

Question 41

BBW of leflunamide

Answer 41

Hepatotoxicity, Pregnancy (needs 2 forms of birth control, wait 2 ys after DC or accelerate drug elimination)

Question 42

What are the accelerated elimination options for leflunamide?

Answer 42

1. Cholestyramine 8 g PO TID for 11 days (use 4 g if 8 g is not tolerated) 2. Activated charcoal suspension 50 g PO Q12H x 11 days

Question 43

JAK inhibitors

Answer 43

Tofacitinib Baracitinib Upadacirinib

Question 44

Tofacitinib

Answer 44

Xeljanz

Question 45

Baracitinib

Answer 45

Olumiant

Question 46

Upadacitinib

Answer 46

Rinvoq

Question 47

BBW of JAK inhibitors

Answer 47

Serious infections Malignancy Thrombosis

Question 48

DDI with MTX

Answer 48

Avoid alcohol → liver toxicity Decreased renal elimination of NSAIDS

Question 49

ANti-TNF DMARDs for RA

Answer 49

Etanercept Adalimumab Infliximab Certolizaumab pegol Golimumab

Question 50

Etanercept

Answer 50

Enbrel

Question 51

Adalimumab

Answer 51

Humira

Question 52

Infliximab

Answer 52

Remicade

Question 53

Certolizumab pgol

Answer 53

Cimzia

Question 54

Golumumab

Answer 54

Siponi

Question 55

Duration of Etranecpt

Answer 55

SC QW

Question 56

Duration of Humira

Answer 56

every other week

Question 57

How to administer Remicade

Answer 57

Requires filter and NS only

Question 58

Duration ceralizumab

Answer 58

SC every other week

Question 59

Duration of golimumab

Answer 59

Monthly requiring a filter

Question 60

BBW of anti TNF

Answer 60

Malignancies Serious infection (screen for latent TB and treat)

Question 61

ADR of antiTNF

Answer 61

Demyelination, Hep B reactivation, HF, hepatotoxity, lupus-like syndrome Avoid other biologic DMARDs or live vaccines

Question 62

Indication for anti-tnf

Answer 62

Add on therapy to MTX for severe presentations

Question 63

Storage of biologic DMARDs

Answer 63

Refrigeration → open room temp x 14 days Don't shake or freeze

Question 64

MOA of rituximab

Answer 64

Depletes CD20 B cells

Question 65

Rituximab

Answer 65

Rituxan

Question 66

Administration of Rituxan

Answer 66

Premedicate with h steroid, APAP, and antihistamine

Question 67

BBW of rituximab

Answer 67

Infusion-related reactions HBV reactivation (screen for Hep B and C

Question 68

BBW of IL-receptor antagonist

Answer 68

Infection → screen for TB

Question 69

Population prone to SLE

Answer 69

AA and Asian descent

Question 70

Drugs that cause DILE

Answer 70

Methimazole PTU Methyldopa Minocyline Procainamide Hydralazine Anti-TNF Terbinafine Isoniazid Quinidine

Question 71

Presentiations of SLE

Answer 71

Nose bridge and cheeks are red Butterfly rash Fatigue, depression, anorexia, weight loss, muscle pain, photosensitivity, joint pain and stiffness

Question 72

Most common complication of lupus

Answer 72

Lupus nephritis (50% of patients)

Question 73

Labs of lupus

Answer 73

ANA anti-ssDNA ant-dsDNS Antiphospholid antibodies

Question 74

Non pharm for lupus

Answer 74

Sunscreen and sun protection

Question 75

Immunosuppressant and cytotoxic drugs for lupus

Answer 75

Hydroxychloroquine Cyclophosphamide Azathiopurine Mycophenolate mofetil Cyclosporine May take up to 6 months

Question 76

Biologics for lupus

Answer 76

Belimumab Voclosporin

Question 77

MOA of belimumab

Answer 77

IgG1-lambda monoclonal antibody: prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocytes to receptors B lymphocytesB

Question 78

Belimumab

Answer 78

Benlysta

Question 79

Warning of Belimumab

Answer 79

Infection Don't use with biologic DMARDs or live vaccines

Question 80

MOA of voclosporin

Answer 80

Calcineurin inhibitor: suppress immune system by inhibiting T-lymphocyte activation

Question 81

BBW of voclosporin

Answer 81

Malignancies, infections

Question 81

ADR of voclosporin

Answer 81

Nephrotoxicyt, HTN, No live vaccines HA, Diarrhea, renal impairment

Question 82

What is multiple sclerosis

Answer 82

Immune system attacks the myelin sheath

Question 83

Sx of MS

Answer 83

Fatigue, numbness, blurred vision Cognitive decline, muscle spasms, pain, bladder spasticity, gait instability

Question 84

Glatiramer acetate

Answer 84

Copaxone

Question 85

ADR Glatiramir

Answer 85

Chest pain, inj site rx, diaphoresis, flushing Preferred in pregnancy

Question 86

Duration of Glatiramer

Answer 86

SC QD or SC 3 times per week

Question 87

Interferon beta 1a and duration

Answer 87

Avonex: IM QW Rebif: SC 3 x per week

Question 88

Interferon beta 1b and duration

Answer 88

Betaseron, extavia every other day

Question 89

Peginterferon beta-1a and duration

Answer 89

Plegridy: Q14D

Question 90

ADR of interferon beta products

Answer 90

Psychiatric disorders, injection site necrosis, ↑ LFTs, thyroid dysfunction Flu-like sx

Question 91

Storage of interferon beta 1b products

Answer 91

If refrigerated, let it stand at room temp prior Don't expel the small air bubble due to loss of dose

Question 92

BBW of Natalizumab

Answer 92

PML → REMS

Question 93

NAtalizumab

Answer 93

Tysabri

Question 94

Sx control for MS

Answer 94

Anticholinergics: incontinence, laxative, muscle relaxants, analgesics Propranolol: tremors

Question 95

ADR of sphingosine 1 phosphate receptor modulators

Answer 95

Bradycardia, Infection (screen for VZV), macular edema (eye exams), hepatotoxicity

Question 96

What is Rayna's phenonmen

Answer 96

Cold and stress → vasospasm of appendagesTx

Question 97

Tx for Raynauds

Answer 97

Nifedipine → vasodilation

Question 98

What is celiac disease

Answer 98

Immune response to gluten (rye, wheat, barley)

Question 99

Tx of celiac

Answer 99

Avoid gluten entirely

Question 100

Sx of celiac disease

Answer 100

Diarrhea, weight loss, bloating, ab pain

Question 101

What is myasthenia gravis

Answer 101

Autoimmune that attacks the connection between nerves and muscles → muscle weakness

Question 102

Sx of MG

Answer 102

Eye/vision changes, facial drooping (ptosis)

Question 103

Drugs that can worsen MG

Answer 103

AG, FQ, and Macrolides Magnesium BB and CCB Antipsychotics Muscle relaxants Botox

Question 104

Tx for MG

Answer 104

Pyridostigmine

Question 105

MOA of Pyridostigmine

Answer 105

Blocks the breakdown of Ach → improves neuromuscular transmission and ↑ muscle strength

Question 106

ADR of Pyridostigmine

Answer 106

Cholinergic effects: salivation, lacrimation, urinartion, diarrhea

Question 107

What id sjogren syndrome

Answer 107

Chronic dry eyes and mouth

Question 108

Complications of sjogren syndrome

Answer 108

Dental caries, corneal ulceration, chronic oral infection

Question 109

Tx for dry eyes

Answer 109

Cyclosporine Liftegrast

Question 110

ADR of restasis

Answer 110

Ocular burning

Question 111

ADR of Liftegrast

Answer 111

Unusual taste

Question 112

How long does it take for Restasis to work

Answer 112

3-6 months

Question 113

Tx for dry mouth

Answer 113

Sugar free chewing gum (xylitol) or lozenges Rinse with antimicrobial mouthwash Muscrainic agonist: Pilocarpine, cevimeline → CI in glaucoma and uncontrolled asthma

Question 114

How does psoriasis differ from eczema

Answer 114

Raised, red patches → Silvery-white buildup

Question 115

Non drug tx for psoriasis

Answer 115

UV light → kills T cells in skin UVB

Question 116

First line treatment for psoriasis

Answer 116

Topical: - High potency steroid (short term) - Coal tar (messy) -- Tapinarof (VTAMA) - Anthralin - Tazarotene - Calcipotriene

Question 117

Systemic tx for psoriasis

Answer 117

Retinoid PDE4i IL receptor antagonist Selective tyrosine kinase 2 inhibitor