Systemic Steroids & Autoimmune Conditions

Steroids Dose Equivalence (both PO, IV)

Low to High Potency

• Cute Helpful Pharmacist & Physicians Marry Together & Deliver Babies

Cortisone	25 mg	Short-act.
Hydrocortisone	20 mg	Short-act.
Prednisone	5	Intermediate
Prednisolone	5	Intermediate
Methylprednisolone	4	Intermediate
Triamcinolone	4	Intermediate
Dexamethasone	0.75	Long-act.
Betamethasone	0.6	Long-act.

Glucocorticoids (Systemic Steroids)

Cortisone

Hydrocortisone (Solu-Cortef)

Prednisone

Prednisolone (Millipred, Orapred ODT)

Methylprednisolone (Medrol, Solu-Medrol)

Triamcinolone (Kenalog)

Dexamethasone (Decadron)

Betamethasone

[With Food; Adrenal Suppression - MUST TAPER]

[Short Term SE (<1 month): Fluid retention, GI upset, Emotional instability, Insomnia, increased appetite, Weight gain, Acute increase in BG/BP]

Immunosuppression From Steroids

Immunosuppressed When:

• >/= 2 mg/kg/day of prednisone or prednisone equivalent for > 2 weeks

• >/= 20 mg/day of prednisone or prednisone equivalent for > 2 weeks

[Avoid Live Vaccines; Taper when D/C (reduce ~10-20% every few days]

Rheumatoid Arthritis Treatment

Symptomatic Relief/Bridging Option

• Steroids (lowest dose & shortest duration)

• NSAIDs (high dose - consider GI bleeds & CVD risk)

Treatment

• csDMARDs (First Line)

  • Methotrexate (Drug of Choice)

Moderate-Severe RA Despite csDMARDs

• Biologic (bDMARDs) + csDMARDs

• Targeted synthetic (tsDMARDs) + csDMARDs

NEVER TWO biologic DMARDs or bDMARDs + tsDMARDs***

cDMARDs (Non-Biologic)

Methotrexate (Trexall) [MTX]	7.5-20 mg once weekly (PO, SC, IM) - NEVER QD Boxed - Hepatotoxicity, Myelosuppression, Mucositis/Stomatitis, Pregnancy Monitor Hep B & C Folate (Vit-B9) supplement to reduce hepatic & GI SE
Hydroxychloroquine (Plaquenil)	Irreversible retinopathy (eye exam) QT prolongation Alternative to MTX
Sulfasalazine	AVOID in sulfa or salicylate allergy yellow-orange coloration of skin/urine
Leflunomide	Boxed - Hepatotoxicity, Pregnancy negative pregnancy test, 2 birth control, wait 2 years after D/C, or use accelerated drug elimination procedure

tsDMARDs; Janus Kinase Inhibitors

MOA: Inhibits the JAK enzyme

Tofacitinib (Xeljanz)

Baricitinib (Olumiant)

Upadacitinib (Rinvoq)

[Boxed - Infection, Malignancy, Thrombosis]

[AVOID alcohol]

bDMARDs; Tumor Necrosis Factor (TNF) Inhibitors

Etanercept (Enbrel) - SC weekly

Adalimumab (Humira) - SC every other week

Infliximab (Remicade) - IV (NS only)

Certolizumab pegol (Cimzia) - SC every other week

Golimumab (Simponi) - SC monthly

[Boxed - Infections; Screen for latent TB & treat if needed]

[Demyelinating disease, Hep B reactivation, HF, Hepatotoxicity, Lupus-Like Syndrome]

Other bDMARDs

Rituximab (Rituxan)

• Depletes CD20 B cells

[Boxed - Infusion-related reactions, PML due to JC virus, SJS/TEN]

[HBV reactivations - screen HBV & HCV high-risk groups]

[Premedicate w/ steroid, acetaminophen, and an antihistamine]

Anakinra

• IL1 anatgonist

Abatacept

• Binds to CD80 & CD86 to inactivate T-cell

Tocilizumab, Sarilumab

• IL6 antagonist

[Boxed - infections, screen TB]

Systemic Lupus Erythematosus (SLE)

• Butterfly rash, photosensitivity (sunscreens), joint pain, stiffness

• Lupus nephritis (kidney disease) 50% of PT

• positive labs - Antinuclear antibodies (ANA), anti-ssDNA, anti-dsDNA

Drug Treatment (ALL up to SIX months)

• Hydroxychloroquine, Cyclophosphamide, Azathioprine, Mycophenolate mofetil, Cyclosporine

• Belimumab (Benlysta) - IgG1 lambda monoclonal antibody

  • AVOID with bDMARDs

• Voclosporin - Calcineurin Inhibitor

  • Nephrotoxcity; AVOID with live vaccines

Drugs that Cause DILE

Methimazole

Methyldopa

Minocycline

Propylthiouracil

Procainamide

Hydralazine

Anti-TNF agents

Terbinafine

Isoniazid

Quinidine

Multiple Sclerosis

• Immune system attacks the myelin sheath

PTs who are actively trying to conceive 

• Glatiramer Acetate (Copaxone)

• Interferon beta formulations (Betaseereon, Avonex, Rebif, Extavia, Plegridy)

PTs who need treatment during pregnancy

• Glatiramer Acetate (Copaxone)

Oral Disease Modifying Agents (DMTs) used as Initial Treatments for PT With Relapsing Remitting MS

• Fingolimod, Ozanimod, Ponesimod, Siponimod

Drugs for Symptom Control

• Anticholinergics for incontinence

• Laxatives for constipation

• Muscle relaxants

• Analgesics

• Propranolol for tremor

Raynaud’s

Drugs that Cause or Worsen Raynaud’s

• Beta-blockers

• Belomycin, Cisplatin

• Amphetamines (e.g., Concerta, Vyvanse)

• Pseudoephedrine

• Illicit drugs

Drugs for Prevention

• CCBs - Nifedipine (most common)

Celiac Disease

• AVOID GLUTEN

  • Protein found in wheat, barley, rye

Myasthenia Gravis

• eye/vision change, drooping eyelid (ptosis)

Treatment

• Pyridostigmine - Cholinesterase inhibitor (inhibits breakdown of aCh)

  • Cholinergic SE

Sjogren’s Syndrome

• severe dry eyes & dry mouth

Treatment of Dry Eyes

• Cyclosporine Emulsion (Restasis)

  • Ocular (burning) SE

Treatment of Dry Mouth

• OTC - Xylitol or Lozenges & daily antimicrobial mouthwash

• Rx - Pilocarpine or Cevimeline

  • Muscarinic agonists

  • AVOID in PT with uncontrolled asthma & narrow-angle glaucoma