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NAPLEX 2021 > Systemic Steroids and Autoimmune Conditions > Flashcards

Systemic Steroids and Autoimmune Conditions Flashcards

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1
Q

Why are steroids used in adrenal insufficiency?

A

to replace endogenous steroids that adrenal gland is not producing enough of

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2
Q

which endogenous steroids requirement replacement in adrenal insufficiency?

A

Cortisol -> replaced by any steroids

Aldosterone -> replaced by fludrocortisone

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3
Q

what does aldosterone/fludrocortisone do?

A

it has mineralocorticoid activity

AKA maintains the balance of water and electrolytes to keep blood pressure stable

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4
Q

what are the indications for fludrocortisone?

A

FDA: Addison’s

Non-FDA: orthostatic hypotension

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5
Q

What does glucocorticoid activity entail?

A

anti-inflammatory effects

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6
Q

What can systemic steroids with glucocorticoid activity cause the adrenal gland to do?

A

stop producing cortisol due to feedback inhibition

HPA axis suppression!

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7
Q

Why is it important to taper off steroids?

A

so the adrenal gland has time to resume cortisol production

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8
Q

Explain the HPA axis

A

Hypothalamus produces CRH (cortisol releasing hormone) which stimulates the pituitary gland to release ACTH (adrenocrticotropic hormone) which stimulates the adrenal glands to produce cortisol. Cortisol suppresses ACTH and CRH produces vai negative feedback

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9
Q

how does Cushing’s develop?

A

adrenal gland produces too much cortisol or exogenous drugs are taken in high doses

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10
Q

How does Addison’s develop?

A

opposite of Cushing’s! it’s when the adrenal gland is not making enough cortisol or if exogenous steroids are stopped suddenly (Addison’s crisis) = fatal!

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11
Q

Adverse effects of cushing’s

A 
Psychiatric chcanges
acnes
glaucoma
moon face/buffalo hump
stretch marks 
muscle wasting 
impaired wound healing
diabetes
irregular periods/hirsutism 
poor bone health 
gi bleeding/ulcers
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12
Q

ways to reduce the adverse effect of steroids

A

alternate day dosing
use localized therapy (inhaltion for lungs, injection for joints)
lowest possible dose for shortest amount of time

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13
Q

which steroid has low systemic absorption?

A

budesonide

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14
Q

Steroids least to most potent and dose equivalence

A 
Cortisone 25mg 
Hydrocortisone 20mg
Prednisone 5 mg
Prednisolone 5 mg 
Methylprednisolone 4 mg 
Triamcinolone 4 mg
Dexamethasone  0.75 mg 
Betamethasone 0.6 mg
"Cute Hot Pharmacists and Physicians Marry Together and Deliver Babies"
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15
Q

Contraindications for systemic steroids

A

Live vaccines, serious systemic infections

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16
Q

prodrug of cortisol

A

cortisone

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17
Q

prodrug of prednisolone

A

prednisone

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18
Q

which steroid is typically used in children?

A

prednisolone (liquid form)

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19
Q

At what dose and time period is a patient on steroids considered immunosuppressed

A

> 2mg/kg/day for > 2 weeks

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20
Q

lab tests that can detect inflammation in autoimmune disorders

A

ESR
CRP
RF
ANA (anti-nuclear antibody)

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21
Q

Why is a high dose given intially then tapered down?

A

to prevent Addison’s crisis AND

quickly reduce inflammation then treat remaining inflammation while preventing a rebound attack

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22
Q

what conditions does the use of strong immunosuppressants increase the risk of?

A

re-activating TB/HepB and C : test and treat before starting
live vaccine virus : vaccinate before starting immunosuppressants
Lymphoma/skin cancers
fungal/bacterial infections - monitor CBC

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23
Q

RA presents bilaterally/symmetrically or unilaterally?

A

bilaterally/symmetrically

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24
Q

OA presents bilaterally/symmetrically or unilaterally

A

unilaterally

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25
Symptoms of RA
``` systemic! fever, weakness, loss of appetite, worsening stiffness after rest (morning stiffness) joint swelling bone deformity edema redness ```
26
does OA cause prolonged stiffness?
NO!
27
how to diagnosis RA
test for ACPA (anti-citrullinated peptide antibdoy) and RF | if later in disease state will see joint erosion and rheumatoid nodules
28
what should a patient be started on if symptomatic despite severity level?
DMARD
29
how do DMARDs work?
slow disease progression and prevent further joint damage
30
Preferred initial therapy in most patients?
Methotrexate
31
What is preferred therapy in patients with mod-severe RA
combo of DMARD or TNF inhibitor biologic or a non-TNF biologic with/without MTX
32
What should never be done with RA drug treatment
using 2 biologics together! | Risk of serious infections!
33
when can you use a low dose steroid in RA patients/
when starting a DMARD in a moderate or severe patient to provide some relief while waiting for the DMARD to work or in patients with hx of dmard failure
34
MOA of MTX
inhibis dihydrofolate reductase inhbiting folate causing immune modulator and anti-inflammatory activity
35
RA dosing for MTX
7.5 - 20 mg once WEEKLY! | daily dosing in RA leads to liver damage and intestinal bleeding
36
monitoring with MTX use
cbc lfts chest x-ray hep B and C serologies
37
what can be given with MTX to decrease Gi and hepatic side effects
folate
38
Warnings with hydroxychloroquine
irreversible retinopathy - eye exam needed!
39
counseling note with sulfasalazine
yellow-orange color of skin/urine
40
MOA of leflunomide (Arava) f
inhibits pyrimidine synthesis causing anti-proliferative and anti-inflammatory effects
41
which traditional DMARDs are teratogenic?
MTX and Leflunomide
42
Warnings with leflunomide
DNU in pregnancy hepatotoxicity SJS risk Accelerated drug elimination process needed upon d/c to lower levels of teriflunomide (active metabolite)
43
what DMARD requires accelerated drug elimination?
leflunomide
44
what are the two accelerate drug elimination options with lefluomide?
1. cholestyramine 8 g tid for 11 days | 2. activated charcoal suspension 50 g q 12 h 11 days
45
how long must a patient wait if wanting to get pregnant after using leflunomide?
2 years or use accelerated drug elimination procedure
46
List of Janus Kinase Inhibitors (JAK)
Tofacitinib (Xeljanz) Baricitinib (Olumiant) Upadacitinib (Rinvoq)
47
JAK inibitor MOA
Inhibit the enzyme janus kinase which stimulates immune cells
48
Boxed warnings with JAK inhibitors
serious infections malignancy risk increase thrombosis risk
49
Special warning with Xeljanz (tofacitinib)
increased mortality in patient >50 years old with 1 or more CV risk and taking higher dose
50
Interactions with MTX
``` alcohol - liver tox NSAIDs/beta lactams/probenecid - renal tox sulfonamides and topical tacrolimus loops cyclosporines ```
51
List of Anti-TNF (tumor necrosis factor) alpha inhibitors
``` etanercept (Enbrel) adalimumab (Humira) infliximab (Remicadde) certolizumab pegol (Cimzia) golimumab (Simponi) ```
52
Etanercept (enbrel) dosing schedule
50 mg sc WEEKLY
53
Adalimumab (humira) dosing schedule
40 mg sc EVERY OTHER week | without MTX: weekly
54
Infliximab dosing (Remicade)
3 mg/kg IV weeks 0,2,6 then every 8 weeks | can do 10mg/kg or every 4 weeks but increased infection risk
55
Remicade preparation
filter needed | only stable in Normal saline
56
what's something unique about hypersensitivity reactions with Remicade?
delayed (3-12 days) after administartion
57
Simponi (golimumab) dosing
50 m gmonthy for sc | 2mg/kg IV at week 0,4 then every 8
58
Which anti-TNF biologic DMARDs require filters?
Simponi (golimumab) and Remicade (infliximab)
59
CI specific for infliximab
doses >5 mg/kg in mod-severe heart failure
60
CI specific for etanercept
sepsis
61
role of anti-TNF biologics
add-on therapy with MTX unless the presentation is severe, then can be started as initial therapy with or without MTX

NAPLEX 2021 (28 decks)

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