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Steroids and Autoimmune

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munsele's version from 2016-06-28 00:22

Section 1

Question Answer
Primary endogenous glucocorticoidCortisol
Primary endogenous mineralocorticoidAldosterone
Mineralocorticoid used for replacement in Addison'sFludrocortisone
Long term steroid SEOsteo, glaucoma, CVD, hyperglycemia, HTN, adrenal suppression, immunosuppression
Cushing SyndromeCondition d/t excess endogenous cortisol or exogenous steroid therapy
S/sx of CushingsCentral redistribution of fat, moon facies, buffalo hump, impaired wound healing, dermal thinning/bruising
Relative steroid potency in orderBetamethosone/dex, methylprednisolone/triamcinolone, prednisone/prednisolone, hydrocortisone, cortisone
When should steroid dose be given if dosed QDBetween 7-8am to mimic the body's release of cortisol
Triamcinolone Kenalog, Aristospan
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Section 2

Question Answer
RA, disease length and whether symmetrical chronic, symmetrical disease
RA causes inflammation ofJoints and other organs including kidneys, eyes, heart, and lungs
RA typical area of first presentationhands and feet
Classic RA sxJoint swelling, stiffness, pain, and bone deformity
OA vs RA for stiffnessOA doesn't cause stiffness -- morning stiffness is clue for RA (up to 2h after waking)
Non drug RA therapyRest, PT, OT, excerise, diet, wt control, and surgery
RA diagnosisMorning stiffness lasting >1h, soft tissue swelling >3 joints, swelling of hand, foot or wrist joints; symmetric, rheumatoid nodules, positive serum rheumatoid factor, radiographic erosions in hand or wrist joints
RA drug therapy optionsDMARD, MTX< TNF inhibitor,
RA preferred initial therapyMTX
DMARD role in therapystart regardless of severity to slow disease process and prevent further damage
MTX brand namesOtrexup, Rasuvo, Rheumatrex, Trexal
MTX dosingOnce weekly; 2.5mg q 12 x 3 once weekly
MTX SEN/V/D, increased LFTs, stomatitis, alopecia, photosensitvity
MTX PG CatX
Use with folateTo decrease hematological, GI, and hepatic SE. Give 5mg PO day following MTX
MTX MOAIrreversibly binds and inhibits dihydofolate reductase, inhibiting folate, thymidylate, and purine
MTX immune modulator or anti-inflammatoryBOTH
Methotrexate drug interactionsAlcohol, ASA/NSAIDs, b-lactams, probenecid, sulfonamides, tacrolimus, cyclosporine
Methotrexate decreases efficacy of which medsLoops
MTX max dose 20mg weekly
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Section 3

Question Answer
HydroxyclooroquinePlaquenil
Plaquenil SEVision changes, HA, rash, pruritus, pigmentation changes in skin and hair, N/V/D, abdominal pain
SulfasalazineAzulfidine, EN-tabs,
Sulfasalazine CIsulfa or salicylate allergy
Sulfa SEfolate def, rash, dyspepsia, rash, HA
Sulfa suppcan give with flat 1mg.day
Sulfa PG CatB
Sulfa effect on skin/urineyellow-orange coloration
LeflunomideArava
Leflunomide Boxed WarningsEmbryo-fetal toxicity, hepatotoxicity
Leflunomide accelerated removal options (for when med is d/c)Cholestyramine, activated charcoal (11 days for both!!)
Plaquenil MOAImmune modulator
Sulfa MOAImmune modulator
Leflunomide MOAInhibits Pyrimidine synthesis resulting in anti proliferative and anti-inflammatory effects
Arava in PGContraindicated
Plaquenil in PGContraindicated
TofacitinibXeljanz
Xeljanz Boxed warningsSerious infections including TB, fugal, viral, bacterial and opportunisitc
Xeljanz PG CatC
Xeljanz caution in which populationAsian, increase frequency of SE
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Section 4

Question Answer
EtanerceptEnbrel, SureClick
AdalimumabHumira
InfliximabRemicade
CertolizumabCimzia
GolimumabSimponai
TNF alpha inhibitor boxed warningsserious infections, HF, hepatotoxicity!!
TNF alpha inhibitor monitoringTB test, s/sx of infection
TNF alpha inhibitor storageRequires refrigeration (room temp for max of 14 days for Enbrel and Humira)
TNF alpha inhibitor use with MTXAdd-on therapy to MTX. If initial presentation is severe these can be started as initial
Enbrel reconstitution visualfoaming is normal
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Section 5

Question Answer
Rituximabdepletes CD20 B cells
Rituximab Boxed warningsHBV reactivation, screen for latent TB and HBV
Anakinra MOAIL-1 receptor antag
AnakinraKineret
Anakinra screeningTB prior to usage
Abatacept MOAT cell costimulator (selective)
Abatacept Orencia
TocilizumabActemra
Tocilizumab IL-6 receptor antag
Cat C agentsAbatacept, Rituximab
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Section 6

Question Answer
SLE sxfatigue, depression, anorexia, wt loss, myalgia, malaria rash (butterfly rash)
Manifestations contributing to morbidity and mortalityRenal, hematologic, and neurologic
Lupus nephritis develops in what percentage of pts50%
Meds associated with causing LupusProcainamide, Hydralazine, Isoniazid, Quinidine, Methyldopa, PTU, methimazole, Minocycline, terbinafine, anti-TNF agents
Agents used in SLEHydroxychloroquine, Prednisone, Mycophenolate, Belimumab
Hydroxychloroquine length to benefit6 mo
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Section 7

Question Answer
Glatiramer AcetateCopaxone
Copaxone dosing 20mg QD, or 40mg 3x/wk
Interferon 1aAvonex, Rebif
Interferon 1bBetasseron, Extavia
Peg interferon beta-1aPlegridy
Interferon SEFlu like sx
TerifluomideAubagio (oral tablet)
FingolimodGilenya
Dimethyl fumarateTecfidera
Fingolimod monitoring monitor for 6 hours following first dose
Fingolimod WarningsBrady, macular edema
Fingolimod SEHA, diarrhea, flu like sx, back pain, increase in LFTs
AlemtuzumabLemtrada
Alemtuzumab SERash, HA
Alemtuzumab and antiviral prophylaxisStart on first day of each course and continue for 2mo or until CD4 count >200
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Section 8

Question Answer
Raynaud's preventionNifedipine
Celiac sxdiarrhea, abdominal pain, bloating, and wt loss
Celiac is immune response to eatinggluten
Sjogren'ssevere dry eyes and mouth
Drops for dry eyesCyclosporine (Restates)
Muscarinic agonists for dry mouthPilocarpine and Cevimeline
PilocarpineSalagen
CevimelineEvoxac
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Section 9

Question Answer
Psoriasis non drug therapyUVB phototherapy
Topical tx optionsCalcipotriene, anthralin, Tazorotene, salicylic acid, coal tar, moisturizers
Systemic agentsStellar, Otezla, Cosentyx
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