RxPrep Systemic Steroids & Autoimmune Conditions Part 1 (Systemic Steroids, RA, SLE)

adrenal insufficiency, inflammatory conditions

Steroids are commonly used in what 2 conditions?

fludrocortisone

What steroid mimics aldosterone?

mineralocorticoid

Fludrocortisone has (glucocorticoid/mineralocorticoid) activity, which is used to maintain a balance of water and electrolytes.

Addison's disease; orthostatic hypotension

Fludrocortisone is FDA approved for ________ but is also used off-label for ________.

glucocorticoids

(Glucocorticoids/Mineralocorticoids) have more anti-inflammatory effects.

adrenal gland; cortisol

Systemic steroids can cause the ________ to stop producing ________ due to feedback inhibition.

hypothalamic-pituitary-adrenal axis

What does HPA axis stand for?

HPA axis

Systemic steroids can cause suppression of the ________.

true

True or False: When long-term steroids are discontinued, they need to be tapered off to give the adrenal gland time to resume cortisol production.

Cushing's syndrome

condition that can develop when the adrenal gland produces too much cortisol, or if exogenous steroids are taken in doses higher than the normal amount of endogenous cortisol

Addison's disease

condition where the adrenal gland is not making enough cortisol

Addisonian crisis

What can occur if exogenous steroids are stopped suddenly?

hypotension, volume depletion

What are 2 hallmarks of an Addisonian crisis?

alternate day dosing

What is something that can be done to decrease Cushing-like side effects due to systemic steroid use?

use steroid w/ low systemic absorption

What is something that can be done to reduce systemic steroid risks when treating a condition in the gut?

Cute Hot Pharmacists and Physicians Marry Together & Deliver Babies

What is a "silly sentence" that can be used to remember systemic steroids in order from least to most potent?

b; d; g; f; e; h; c; a

Put the following systemic steroids in order from least to most potent.

a) betamethasone

b) cortisone

c) dexamethasone

d) hydrocortisone

e) methylprednisolone

f) prednisolone

g) prednisone

h) triamcinolone

b, d

Which of the following systemic steroids are short-acting? (select all that apply)

a) betamethasone

b) cortisone

c) dexamethasone

d) hydrocortisone

e) methylprednisolone

f) prednisolone

g) prednisone

h) triamcinolone

e, f, g, h

Which of the following systemic steroids are intermediate-acting? (select all that apply)

a) betamethasone

b) cortisone

c) dexamethasone

d) hydrocortisone

e) methylprednisolone

f) prednisolone

g) prednisone

h) triamcinolone

a, c

Which of the following systemic steroids are long-acting? (select all that apply)

a) betamethasone

b) cortisone

c) dexamethasone

d) hydrocortisone

e) methylprednisolone

f) prednisolone

g) prednisone

h) triamcinolone

a) 25

b) 20

c) 5

d) 5

e) 4

f) 4

g) 0.75

h) 0.6

What are the following systemic steroid (PO, IV) dose equivalences?

a) cortisone = ________ mg

b) hydrocortisone = ________ mg

c) prednisone = ________ mg

d) prednisolone = ________ mg

e) methylprednisolone = ________ mg

f) triamcinolone = ________ mg

g) dexamethasone = ________ mg

h) betamethasone = ________ mg

100 mg prednisone

(40 x 2) / 4 = x / 5

x = 100

AS is a 30 YOF who presented to the hospital with an acute flare of Crohn's disease. She was started on Solu-Medrol 40 mg IV BID. The medical team is now ready to transition her to oral prednisone at an equivalent dose. Assuming the IV:PO ratio of Solu-Medrol is 1:1, what is the equivalent daily dose?

Decadron

What is the brand name for dexamethasone?

Solu-Cortef

What is the brand name for hydrocortisone?

Medrol, Solu-Medrol

What are 2 brand names for methylprednisolone?

Deltasone

What is the brand name for prednisone?

Millipred, Orapred ODT

What are 2 brand names for prednisolone?

Kenalog

What is the brand name for triamcinolone?

with food

Should oral systemic steroids be taken on an empty stomach or with food?

adrenal suppression

What is a warning associated with systemic steroids?

emotional instability, increased appetite, insomnia, weight gain

What are 4 short-term side effects of systemic steroids?

cortisol

Cortisone is a prodrug of ________.

prednisolone

Prednisone is a prodrug of ________.

methylprednisolone

What systemic steroid is available in a therapy pack and as an injection?

≥2; ≥20; >2 weeks

A patient is immunosuppressed when using ________ mg/kg/day or ________ mg/day of prednisone or prednisone equivalent for ________.

10-20

A common method for systemic steroid tapering is to reduce the dose by ~________% every few days.

7-14 days

Systemic steroid tapers can last for ________ depending on the condition being treated.

21

How many tablets are included in a Medrol therapy pack?

4 mg

What strength are the tablets in a Medrol therapy pack?

6 days

The Medrol therapy pack uses a tapered dose schedule over the course of ________.

fatigue, pain, weakness

What are 3 common symptoms of most autoimmune diseases?

erythrocyte sedimentation rate

What does ESR stand for?

C-reactive protein

What does CRP stand for?

rheumatoid factor

What does RF stand for?

anti-nuclear antibody

What does ANA stand for?

ANA, CRP, ESR, RF

What are 4 non-specific laboratory blood tests that can be useful in detecting inflammation in autoimmune conditions?

hepatitis B, hepatitis C, infections, lymphomas, skin cancers, tuberculosis, viruses

Use of strong immunosuppressants can increase the risk of what 7 conditions?

before

Testing and treatment for tuberculosis, hepatitis B, and hepatitis C must be done (after/before) starting immunosuppressive drugs.

before

If a virus can be prevented by a live vaccine, the vaccine must be given (after/before) starting immunosuppressive treatment.

lymphomas, skin cancer

What 2 types of cancers are normally suppressed by a competent immune system?

rheumatoid arthritis

What does RA stand for?

RA

chronic, progressive autoimmune disorder that primarily affects the joints

bilateral; symmetrical

(Bilateral/Unilateral), (asymmetrical/symmetrical) disease is consistent with an RA diagnosis.

rest

With RA, stiffness and pain are worse after (exertion/rest).

RA

(OA/RA) causes prolonged stiffness.

osteoarthritis

What does OA stand for?

anti-citrullinated peptide antibody

What does ACPA stand for?

ACPA, RF

What are 2 laboratory tests that are useful in diagnosing RA?

bone deformity,

joint swelling,

pain,

stiffness

What are 4 articular symptoms of RA?

disease-modifying antirheumatic drug

What does DMARD stand for?

DMARD

Patients with symptomatic RA should be started on a(n) ________, regardless of the severity of the disease.

DMARD

drug class that slows RA disease processes and helps prevent further joint damage

methotrexate

What is the preferred initial therapy for most patients with RA?

false

(should never use 2 together due to risk of serious infections)

True or False: Two biologic DMARDs are often used in combination to treat RA.

steroids

What drug class is commonly used in RA flares?

lowest; shortest

When using steroids for RA flares, they should be used at the (highest/lowest) dose for the (longest/shortest) duration possible.

Trexall

What is the brand name for methotrexate?

tablet

What drug formulation is Trexall (methotrexate)?

SC auto-injector

What drug formulation do Otrexup and Rasuvo (methotrexate) come in?

methotrexate

DMARD that irreversibly binds and inhibits dihydrofolate reductase, inhibiting folate

7.5-20 mg QW

What is the typical dosing for methotrexate for RA?

IM, PO, SC

What are 3 routes of administration used for methotrexate for RA?

weekly

Low (daily/weekly) doses are used for methotrexate for RA.

take as single dose

What is the safest way to take methotrexate in order to avoid errors?

true

True or False: Methotrexate should never be dosed daily for RA.

liver damage

What is an adverse event that can occur due to taking methotrexate daily for RA?

hepatotoxicity,

mucositis/stomatitis,

myelosuppression,

teratogenicity

What are 4 boxed warnings associated with methotrexate?

CBC,

LFTs

chest X-ray (TB),

hepatitis B and C serologies,

What are 4 monitoring parameters for methotrexate?

folate

What can be given to decrease hematological, GI, and hepatic side effects of methotrexate?

Plaquenil

What is the brand name for hydroxychloroquine?

irreversible retinopathy

What is a warning associated with hydroxychloroquine?

eye exam

What is a monitoring parameter for hydroxychloroquine?

sulfa or salicylate allergy

What is a contraindication for sulfasalazine?

yellow-orange

Sulfasalazine can cause a(n) ________ coloration of the skin/urine.

leflunomide

DMARD that inhibits pyrimidine synthesis resulting in anti-proliferative and anti-inflammatory effects

hepatotoxicity, teratogenicity

What are 2 boxed warnings associated with leflunomide?

pregnancy

What is a contraindication for leflunomide?

activated charcoal, cholestyramine

What are 2 options for accelerated drug elimination of leflunomide?

8 g PO TID x 11 days

What is the cholestyramine dosing for accelerated drug elimination of leflunomide?

50 g PO Q12H x 11 days

What is the activated charcoal suspension dosing for accelerated drug elimination of leflunomide?

leflunomide

What DMARD requires a negative pregnancy test and the use of 2 forms of birth control during treatment?

2 years

If pregnancy is desired, you must wait ________ after discontinuing leflunomide or use an accelerated drug elimination procedure.

Janus Kinase

What does JAK stand for?

JAK inhibitors

Tofacitinib, baricitinib, and upadacitinib are examples of ________ used in RA.

malignancy, serious infections, thrombosis

What are 3 boxed warnings associated with JAK inhibitors?

biologic DMARDs

JAK inhibitors should not be used with ________ or other potent immunosuppressants.

alcohol, aspirin, NSAIDs

What are 3 drug interactions for methotrexate?

tumor necrosis factor

What does TNF stand for?

TNF alpha inhibitor

Each ________ has a pregnancy registry due to the unknown risks to the fetus.

TNF alpha inhibitors

Etanercept, adalimumab, infliximab, certolizumab, and golimumab are examples of ________ used in RA.