NAPLEX steroids and autoimmune

primary endogenous mineralcorticoid and synthetic replacement

Aldosterone (Water/Na Balance); Fludrocortisone (Mineralcorticoid)

Addison's disease

Adrenal insufficiency; steroids will be given as a replacement

when is tapering steroids recommended

Long term steroid use; when being used longer than 10-14 days

Cushing Syndrome

due to excess endogenous cortisol or exogenous steroid therapy

symptoms of Cushing Syndrome

fat redistribution, moon face, buffalo hump, impaired wound healing, dermal thinning/bruising

steroid effect on potassium

hypokalemia

which are the two short acting steroids

cortisone and hydrocortisone

cortisone equivalent to 5 mg prednisone

25 mg

hydrocortisone equivalent to 5 mg prednisone

20 mg

intermediate acting steroids

prednisone, prednisolone, methylprednisolone, triamcinolone

prednisolone equivalent to 5 mg prednisone

5mg

methylpred equivalent to 5 mg prednisone

4mg

triamcinolone equivalent to 5 mg prednisone

4 mg

long-acting steroids

dexamethasone and betamethasone

dexamethasone dose equivalent to 5 mg prednisone

0.75mg

betamethasone equivalent to 5mg prednisone

0.6mg

Millpred

Prednisolone

Orapred ODT

Prednisolone

Decadron

Dexamethasone

Solu-Cortef

Hydrocortisone

Medrol

Methylprednisolone

Solu-Medrol

Methylprednisolone

Kenalog

Triamcinolone

short term ADE of steroids (7)

Fluid retension

Stomach upset

Emotional instability

Insomnia

Increase appetite

Weight gain

Acute increase blood glucose/ blood pressure

cortisone pro-drug of

cortisol

prednisone pro-drug of

prednisolone

immunosuppression from steroids

> 2 mg/kg/day OR > 20 mg/day of prednisone or equivalent for > 2 weeks

• No live vaccines

• Taper off

  • 10-20% every few days

Treating acute inflammation with steroids

Autoimmune treatment risk (4)

Reactivation of tuberculosis or hepatitis

Virus - live vaccine prior to treatment

Lymphomas and certain skin cancers

Infection risk

clue that may differentiate RA from OA

morning stiffness lasting a prolonged time; typically polyarticular and symmetrical (bilateral)

first line treatment for RA

started on DMARD regardless of disease severity; slow progress -- methotrexate usually preferred for initial therapy

low dose steroid

less than or equal to 10 mg/day of prednisone or equivalent -- may be used in patients with high disease activity when starting a DMARD or in patients with DMARD failure (used as bridging)

methotrexate dosing for RA

7.5-20mg once weekly -- divided oral doses of 2.5mg every 12 hours for 3 doses ** never daily**

MOA of MTX

irreversibly binds and inhibits dihydrofolate reductase inhibiting folate, thymidylate synthesis and purines

Trexall

Methotrexate oral tablet

Otrexup

methotrexate SC autoinjector

Rasuvo

methotrexate SC auto injector

boxed warnings on MTX (4)

Hepatotoxicity

Mylosuppression

Mucosistis/somatitis

Pregnancy

folate admin with mtx

given 5 mg weekly on day AFTER mtx admin; helps decrease risk of hematological, GI, and hepatic side effects

MTX monitoring

CBC

LFT

Chest X-ray

Hep B and Hep C serologies

Plaquenill

Hydroxychloroquine

Warning of hydroxychloroquine

Irreversible retinopathy - eye exam at baseline and every 3 onths

QT prolongation

Sulfasalazine - warning & contraindications

SULFA - sulfa allergy (CI)

SA - salicylate allergy (CI)

LA - liver and alopecia

I - yellow-orange skin/urine

leflunomide mechansim

Inhibits pyrimidine synthesis

Prodrug of teriflunomide

how long must pregnancy be delayed after leflunomide d/c

2 years unless accelerated removal procedure used (cholestyramine or activated charcoal)

boxed warnings of lefluonomide

Fetal tox (female and male)

Hepatotoxicity (avoid if ALT > 2x ULN)

accelerated elim of leflunomide

1. cholestyramine 8 g PO TID x 11 days

2. activated charcoal sups 50 g PO Q12H x 11 days

JAK inhibitors names (3)

Tofacitinib

Baricitinib

Upadacitinib

DO NOT USE WITH BIOLOGIC DMARDS or POTENT IMMUNOSUPPRESSANTS

JAK inhibitors BBW

Infection

Malignancy

Thrombosis

methotrexate DDI

alcohol - increased risk of hepatotoxicity

active renal elimin -- inhib by Aspirin/NSAIDs, beta lactams, probenecid

Enbrel

etanercept; anti-TNFa; dosed SC weekly; 90 degree

± MTX

Humira

adalimumab; anti-TNFa; SC every other week; 90 degree

± MTX

Remicade

infliximab; anti-TNAa; IV

+MTX

IV infliximab stability

NS only and requires filter

ADE of infliximab

Infusion reactions

• CAN premedicate with APAP/Steroid/Antihistamine

Delayed hypersensitivity

Cimzia

certolizumab pegol (Cimzia) anti TNF; SC every other week; 90 degree

± MTX

Simponi

golimumab; anti TNF ; SC monthly; 45 degree

IV golimumba - requires filter

+MTX

which two anti-TNF agents given with MTX

simponi (golimumab) and infliximab (Remicade)

Boxed warnings with TNF inhib

Serious infections (ex: latent TB)

Malignancies

Anti-TNFa Warnings

Demyelinating disease

Hep B reactivation

Heart failure

Hepatotoxicity

Lupus like syndrome

DO NOT USE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINES

anti-TNF agents must be kept in fridge but which two may be kept at room temp for a max of 14 days

etanercept (enbrel) and adalimumab (humira)

Rituxan

rituximab; anti-CD20 (depletes CP20 B cells); IV
+MTX

premedicate for rituximab

REQUIRED steroid, apap, and antihistamine

boxed warnings with rituximab

infusion reactions

Hep B reactivation

DO NOT USE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINES

anakinra (kineret)

Non-TNF inhibitor for RA

IL-1 receptor antagonist -- not first line

warnings with anakinra

Malignancy and serious infection

Abatacept (Orencia)

Non-TNF inhibitors for RA

selective T cell co-stimulator that inhibits T cell activation by binding to CD 80 and CD 86

IL-6 receptor antagonist

Tocilizumab (Actemra)

Sarilumab (Kevzara)

IL-6 antagonist BBW and warning

BBW

• Serious infections

• Screen for TB

Warning

• DO NOT GIVE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINE

where can adalimumab not be injected but etanercept and golimumab can?

upper arm; all can be inj into thigh and abdomen

most common ethnicities for SLE

Asian and AA

which organs most affected by SLE

heart, lungs, kidneys, brain

which manifestations of SLE most common

arthritis and cutaneous manifestations

which manifestations of SLE contribute most to morbidity and mortality

renal, hematologic, and neurologic

disease which develops in over 50% of patients with SLE

lupus nephritis

drugs associated with DILE

Many Patient Manifesting Malar Patter Are Hoping To Quit It

Methimazole

PTU

Minocycline

Methyldopa

Procainamide

Hydralazine

Anti-TNF agents

Terbinafine

Isoniazid

Quinidine

Benlysta

Belimumab

Belimumab warnings

Serious infections

DO NOT GIVE WITH OTHER BIOLOGIC DMARDS OR LIVE VACCINE

Voclosporin (Lupkynis)

BBW - infections, malignancy

Warning

• Nephrotoxicity

• Hypertension

• Avoid with live vaccine

SE: hypertension, diarrhea, headache, renal impairment

Copaxone, Glatopa

glatiramer acetate

glatiramer dosing

SC Daily or SC 3 times per week (at least 48 hours apart)

glatiramer warnings/side effects

warning: chest pain

side effects

• injection site reaction

• flushing

• diaphoresis (excessive sweat)

• dyspnea

Preferred agent in pregnancy

Avonex dose

Interferon beta 1a

IM weekly

Rebif dose

Interferon beta 1a

SC TIW

Betaseron or Extavia dose

Interferon beta 1b

SC; every other day

*use within 3 hours of reconstitution

frequency of Plegridy dosing

Peginterferon beta 1a

SC every 14 days

ADE of interferons

Warning

• Psychiatric disorders

• Injection site necrosis

• Increased LFT

• Thyroid dysfunction (hypo/hyper)

SE: flu-like symptoms

which interferons do not need to be refridge

Betaseron and Extavia ==> interferon beta 1b

Note for interferon beta products

DO NOT expel the air buttle in prefilled syringe = loss of dose

Teriflunomide

Active metabolite of leflunomide

Contraindicated in pregnancy- hepatotoxicity and teratogenicity

Sphingosine 1 phosphate receptor modulators (S1P) - used in MS

Fingolimod, Ozanimod, Ponesimod, Siponimod

Siponimod genetic testing for contraindication

CYP2C9 3/3 genotype (testing required before use)

Ozanimod contraindication

Concomitant use of MAO-I

S1P Warning (4)

Barychardia/Bradyarrythmia

• Fingolimod - monitor for at least 6 hours (ECG)

Infection risk

Macular edema - Eye exam

Hepatotoxicity - LFT

Fumarate/Nuclear Factors

Dimethyl fumarate, Diroximel fumarate, Monomethyl fumarate

DO NOT crush, chew, sprinkle!

Tysabri

Natalizumab Injection

REMS program for natalizumab

due to high risk of PML

Alemtuzumab

Has REMS program

which agent is commonly used for prevention of Raynaud's

Nifedipine - but other dihydropyridine CCB can be used

Drug induced Raynaud’s

BBCS - blue blue cold 손 (IPA맥주 - illicit drug; pseudoephedrine, amphetamine)

Beta blocker

Bleomycin

Cisplatin

Sympathomimietics (due to vasoconstriction)

• Amphetamine

• Pseudoephedrine

• Illicit drugs