Systemic Steroids and Autoimmune Conditions

Hormone replaced by giving any steroid

cortisol

hormone replaced by giving fludrocortisone

aldosterone

Fludrocortisone mimics _____ and has -_____ activity

aldosterone

has mineralcorticoid

Mineracorticoid activity:

balance of water and electrolytes - keep blood pressure stable

Fludrocortisone is FDA-approved for:

addison's disease

(used off-label for orthostatic hypotention)

Commonly used steroids (prednisone) have ____ activity

glucocorticoid

glucocorticoid activity:

anti-inflammatory

Systemic steroids cause the adrenal gland to

stop producing cortisol "suppression of the hypothalamic pituitary-adrenal HPA axis

Systemic steroids cause "suppression of the HPA axis (hypothalamic pituitary adrenal axis" meaning they

cause the adrenal gland to stop producing cortisol

CUshing's syndrome can develop when:

the adrenal gland produces too much cortisol or if exogenous steroids are taken in doses higher than normal amount of endogenous cortisol

Opposite of cushing's disease

addison's (adrenal gland is not making enough cortisol)

If exogenous steroids are stopped suddenly, it can cause

addisonian crisis, (sx: volume depletion and hypotension- fatal)

Cushing's syndrom long-term effects

glaucoma, cataracts

acne

psych changes

GI bleeding/esophagitis/ulcers

pink purple stretch marks on abdomen/thighs/arms

thin skin that bruises easily

muscle wasting (thin arms and legs compared to rest of body)

infection, impaired wound healing

poor bone health

diabetes

fat deposits in face (moon face)

buffalo hump

women: hair growth on face: hirsutism

irregular/absent menstrual periods

Ways to reduce systemic steroid risks

alternate day dosing

local injections when possible

low systemic absorption (budesonide) for gut conditions

inhaled steroids for asthma

use lowest possible dose

Systemic steroids PO, IV dose equivalence

Cute Hot pharmacists and physicans marry together and deliver babies

Cortisone = 25

Hydrocortisone = 20

Prednisolone/Prednisone = 5

Methylprednisolone = 4

Triamcinolone = 4

Dexamethasone = 0.75

Betamethasone = 0.6

Solu-Coref is brand name

hydrocortisone

take oral doses of steroids

with food to decrease GI upset

short term side effects of steroids

increased appetitie/weight gain, emotional instability, insomnia

Prodrug of cortisol

cortisone

prodrug of prednisolone

prednisone

Warnings on glucocorticoids

adrenal suppression- taper slowly

A patient is immunosuppressed wehn

using 2+mg/kg/day or 20+mg/day of prednisone or prednisone equivalent for 2+weeks

Lab markers that can be useful in detecting inflammation

ESR

C-reactive protein (CRP)

RF

ANA

strong immunosuppression increases the risk for

viruses, reactivation of TB and hepB and hepC

lymphomas and certain skin cancers normally suppressed by competent immune system

infection

T/F: RA is chronic and progressive

true

RA is (unilateral/bilateral)

(asymmetrical/symmetrical)

Bilateral, symmetrical disease (this is different from OA, which is unilateral)

While morning stiffness is common after rest for RA and OA, ____ does not cause prolonged stiffness

OA

Useful lab tests in RA

ACPA: anti-citrullinated peptide antibody

RF

Nonpharm for RA

rest, PT, OT, exercise, diet and weight control, surgical intervention

Any patient with symptomatic RA should be started on:

DMARD- regardless of severity of disease

Preferred initial therapy for RA

methotrexate

Never use two ____ in combination for RA

two biologic DMARDS due to risk of serious fatal infections

what is added to a patient regimen when starting a DMARD for bridging

low-dose steroids to provide relief while waiting for relief- lowest dose and shortest duration possible

NSAIDS can be used to bridge but are wewaker and less toxic- high doses are required.

Trexall is a generic of _____ in ___ formulation

methotrexate tablet formulation

Dosing of MTX in RA

7.5-20mg once weekly: PO, SC, IM

low weekly doses- safest taken as a single dose rather than divided dose- never dose daily- risk of adverse events- liver damage

T/F: You can recommend a patient split their dose up into daily doses to make it more tolerable

false: this is unsafe practice and the liklihood of adverse events is much higher in daily dosing. weekly dosing is safest

Otrexup and Rasuvo are administered via:

SC auto-injector (MTX)

MOA of MTX

irreversibly bind and inhibit dihydrofolate reductase, inhibiting folate

boxed warning for MTX

hepatotoxicity, meylosuppression, mucositis,stomatitis, pregnancy

T/F: MTX is teratogenic

true

monitoring for MTX

CBC, LFTs, hep B and C serologies, Chest-x ray

notes about MTX

folate can be given to decrease hematological, gi and hepatic side effects: give 5 mg PO weekly on day following MTX

Plaquenil warning

(hydroxychloroquin)

irreversible retinopathy

monitoring includes eye exam

contraindication to azulfidine

(sulfasalazine)

sulfa/salicylate allergy

notes about sulfasalazine

causes yellow-orange coloration of skin/urine