Module 3: Immune + Anti-Inflammatory Medications

Goal for gout medications is to have serum uric acid less than

6

colchicine used as

prophylactic or during acute attack

gout drug that results in myopathy, weakness, neuropathy and malabsorption of B12

colchicine

gout drug that causes hypersensitivity rash (higher in blacks and Hispanics)

allopurinol

sulfa based gout drug that is ok for pregnancy and can be used for older adults (unless renal impairment, in that case= allopurinol)

probenecid

T/F: Uric acid stones when mobilized can cause renal stones

true

colchicine can be used off label in
1.
2.

pericarditis
scleroderma

T/F: NSAIDs can cause increased CV, lipid, hypertension conditions. Topical NSAIDs (votarin 1%) first line for arthritis.

true

Risks with joint injections

risk of infection

steroid joint injections are limited to _____ per year

4

When are steroid joint injections used with arthritis?

need for PT, oral meds, weight loss, overall gradual activity increases

Autoimmune destruction of the joint itself that is highly inflammatory, pain accompanied by joint swelling, erythema, persistent low grade fevers, associated with increased TNF levels

rheumatoid arthritis

First line drugs for RA

DMARDs

nonbiological DMARD that takes about 6 weeks for full effect, aggressive dose increases indicated, can be mixed with other DMARDs, pregnancy category X. Can cause GI distress, stomatitis, folic acid deficiency, photodermatitis, hard on liver, kidney, plat

Methotrexate

Nonbiological DMARD that has an anti inflammatory effect, can cause significant corneal deposits and retinal degeneration. yearly eye exams required. self monitoring with amsler grid (pinhole test) q 2 weeks, tx for prophylaxis of malaria

plaquenil (hydroxychloroquine)

T/F: Never use minocycline in pregnancy.

TRUE because of brown staining on teeth of fetus

nonbiologic DMARD used in mild, early disease with se of photodermatitis, in tetracycline family

minocycline

second line therapy for moderate to severe RA; non biologic DMARD. oral medication. increased r/f infection

tofacitinib (xeljanz)

when do we start biologics in RA?why?

When/if nonbiologics fail; they have strong immunosuppressive effects. pts cannot receive any live vaccines, increased CV and vascular disease, infusion reactions can be severe.

form of biologic medications

infusion medications

Etanercept, infliximab, adalimumab are examples of

biological DMARDs (tnf alpha 1)

abatacept and rituximab are examples of

biological DMARDs (non alpha I)

Hormone released if Ca levels are low and stimulates osteoclasts to resorb bone

parathyroid hormone

Estrogen ______ the bone resorbing action of PTH.

reduces

T/F: Bisphosophopnates are no longer used for preventative therapy.

TRUE

10% loss of BMD = ____x the fracture risk

2x

Patient must sit upright for 1 hour after taking... and take only w/ water

bisphosphonates ex: ibandronate, alendronate, risendronate

how do bisphosphonates work?

inhibit osteoclast activity

RANKL inhibitors are used for __________ that does not respond to other treatments. examples include

denosumab etc.
for those who don't respond to bisphosphonates or who have bone metastasis
injected 2x yearly. positive reduction in vertebral fractures and hip fractures.
impair t- lymphocyte activity.
some cancer risks

pts with G6PD deficiency should avoid which type of abx

fluoroquinolones (-floxacins)

systemic antifungals should be used cautiously for patients with liver problems

true

griseofulvin has possibly cross reactivity with

penicillin

T/F: griseofulvin may decrease efficacy of OCPs.

TRUE

T/F: Stress hormones are secreted by the adrenal cortex.

TRUE

Actions of cortisol

Governs awakeness and sleep patterns
Increases emotional lability
Increases blood glucose
Stimulates protein catabolism
Decrease proliferation of fibroblasts => poor wound healing

Actions of glucocorticosteroids (that are in addition to cortisol actions)

Inhibits immune and inflammatory systems
increases circulating RBCs
increases appetite
promotes fat deposits
promotes lipolysis
increases uric acid excretion
skeletal muscle wasting
promotes acid secretion
decreases serum calcium levels

Aldosterone causes us to retain
1.
2.

retain sodium and water

Aldosterone causes us to excrete
1.

potassium

Corticosteroids are metabolized by the liver into _______ metabolites and excreted by the _____.

active metabolites; excreted by kidneys

C/I for corticosteroid use- 5

active untreated infections
caution w/ HTN and CV disorders
caution w/ those with incr. r/f osteoporosis
caution w/ those w/ diabetes
caution w/ those with UC or PUD for increased risk of perf/GI bleed

ADRs for corticosteroids
1. muscle and skin
2. skeletal tissues
3. eyes
4. GI
5. CV

1. muscle and skin- muscle atrophy, skin thinning, stretch marks, hirsutism, poor healing, truncal obesity, buffalo hump
2. osteoporosis (up to 20% of patients). 10% of persons on long term therapy diagnosed with a fracture.
3. eyes- cataracts, glaucoma,

CNS ADRs for corticosteroids

delirium, agitation, insomnia, mood swings, severe depression

Endocrine ADRs for corticosteroids

adrenal suppression, withdrawal syndrome, if abruptly stopped, affects glucose metabolism

Dosing for hydrocortisone for adrenal insufficiency for adults (full and then taper)

50 mg every 8 hours for 48 hours for adults; then taper to 20 mg a day

Dosing for cortisone for adrenal insufficiency for adults (full and then taper)

25-300mg/day divided twice daily; tapered over 14 days to 15-20 mg/day

Dosing for prednisone for adrenal insufficiency for adults (full and taper)

5 to 60 mg/day divided twice daily, tapered to maintenance 5-20 mg/day

Give morning dose of steroid before what time?

9AM

For immune suppression which steroid is used? why?

prednisone- short half life

first line therapy for Rheumatoid arthritis

NSAIDs

For rheumatoid arthritis, if NSAIDs alone don't work, low-dose __________ can be added to tx regimen

Prednisone- less than 7.5 mg/day

For corticosteroids, you should maintain or increase the dose until...
THEN

acceptable response achieved
THEN
taper to lowest dose that maintains adequate clinical response

Why do we need to slowly taper off steroids?

r/f adrenal insufficiency crisis

T/F: Most conditions that require chronic corticosteroid therapy can be controlled on alternate-day therapy.

TRUE

T/F: Alternate day scheduling retains the whole steroid dose- and doesn't taper.

TRUE

Dietary considerations for steroids

calorie mgmt
diet high in potassium, calcium/ low in sodium and carbs

T/F: NSAIDs inhibit both COX-I and COX-II.

TRUE

cyclooxygenase that is present in all tissues and cells, especially platelets, endothelial cells, the GI tract, and renal microvasculature.

COX-1

cyclooxygenase that is an inducible enzyme synthesized in response to pain and inflammation.

COX-2

T/F: Most NSAIDs are selective or slightly selective toward COX-1.

TRUE

What's the only COX-2 selective NSAID?

Celebrex/celecoxib

Why are COX-2 inhibitors not used as often?

Because of increased CV risk

analgesic/antipyretic that does not effect COX, so does not cause platelet aggregation or GI upset.

Acetaminophen

How does acetaminophen work to
a) reduce pain
b) reduce fever

a) inhibits central and peripheral prostaglandin synthesis
b) reduces fever by direct actions on hypothalamus thermoregulatory center

NSAIDs are metabolized by the ________ and excreted via _______.

liver; kidneys

Acetaminophen carries a risk for

hepatotoxicity

most common ADR for NSAIDs- how do you combat it?

GI disturbances; take w/ food to reduce GI upset, monitor for ulcers and GI Bleeds

NSAIDs _______ platelet aggregation and may _________ bleeding time.

inhibit; increase

NSAID that may aggravate depression or other psychiatric disturbances.

indomethacin

T/F: All NSAIDs can increase risk of thromboembolic complications.

TRUE

Acute hepatic necrosis in acetaminophen OD occurs at which doses? which dose is generally fatal?

10-15 g= hepatic necrosis
25+ g= fatal

What is the tx for acetaminophen OD?

N-acetylcysteine oral solution (Mucomyst, Acetadote)

Indomethacin, naproxen, and sulindac are drugs of choice for
1.
2.
3.

gout pain; tendonitis, bursitis

mild to moderate pain- what is your analgesia of choice?

NSAIDs, acetaminophen

For fever, what is the drug of choice?

ibuprofen

Drug of choice for mild to mod pain and fever in pregnancy, pts with hx of GI bleed, ASA allergy, blood coagulation disorder, children, infants <6 months.

acetaminophen

With long term therapy on NSAIDs, must check for

renal function/CBC

With longer term therapy on acetaminophen, must check for...

liver function

With both NSAIDs and acetaminophen, pts should limit...

alcohol

Max acetaminophen dose is

2-4 g/day

ADRs that patient must report on NSAIDs

severe GI upset/ "coffee ground" emesis/ black tarry stools

_____________ is an analgesic, antiinflammatory, antipyretic, antiplatelet agent that irreversibly inhibits platelet aggregation and inhibits PG synthesis.

aspirin/salicylates

What influences excretion of aspirin?

urine pH

Aspirin can cause __________ in children with flu or chicken pox.

Reye's syndrome

___________ can be ototoxic at higher levels

aspirin

Iron deficiency anemia, gi irritation, ulcers, bleeding are ADRs r/t

aspirin

why to avoid aspirin after surgery

bleeding risk

aspirin is pregnancy category

D

Vomiting, lethargy, delirium, coma in peds pt with influenza or chicken pox may indicate

reye's syndrome- did they take aspirin?

lethal dose of aspirin in adults is ____ to ____g- how is it lethal?

10-30 g; causes respiratory alkalosis

Tx of aspirin OD

emetics or gastric lavage;
ALKALINIZING URINE to increase excretion
hemodialysis for severe poisoning

Daily treatment of 81-325 mg of aspirin has been associated with a 20% reduction in __________ and can also be useful for strokes.

MIs

At the first sign of an MI, patients should take which med?

1 325 mg aspirin tablet

Pt education for aspirin

Take with plenty of water
don't crush or chew coated versions

for long term aspirin, therapy a random salicyclate level should be drawn ______________ days after initiation

7-10 days after initiation

Attenuated is AKA a

live vaccine

Immune response w/ an attenuated vaccine is virtually _______ to natural infection

identical

Attenuated vaccines usually produce immunity with _______ dose, except oral forms.

1

T/F: Attenuated vaccines are fragile.

TRUE- Most be stored/handled carefully

Who should avoid live/attenuated vaccines?

special populations- Immunocompromised, pregnant
TTC- avoid 1 month before becoming pregnant
NOT given if febrile illness
NOT given with antiviral drugs

T/F: Severe reactions are possible with attenuated vaccines.

TRUE

MMR, OPV, varicella, LAIV, Flu mist, rotavirus, Zostavax, BCG are what type of vaccines?

live attenuated vaccines

if patient needs 2 live vaccines, how can you give them?
1. option 1
2. option 2

1. give both same day
2. give them at least 4 weeks apart

Live Influenza/flu mist contraindications (other than pregnancy/immunocompromised)

Egg allergy, asthma

T/F: MMR contains neomycin and gelatin.

TRUE

T/F: MMRV is OK to give to those with egg allergy and to breastfeeding women.

TRUE

T/F: Rotavirus oral vaccine is associated with intussusception.

FALSE

T/F: Varivax can be used as postexposure prophylaxis up to 3 days after exposure to varicella rash.

TRUE

T/F: Do not use antivirals surrounding vaccines.

TRUE- can block immune response

T/F: Inactivated vaccines always require multiple doses, create a mostly humoral immune response, and antibody titer diminishes with time.

TRUE

When to not get the inactivated flu vaccine

egg allergy
GBS hx
not feeling well

How to dose flu vaccine

patients <9 years of age get 2 shots, annual vaccine for those 9-65. 66+ high dose.

DTaP is given before age of ______ and Tdap is given after.

7

When is Tdap booster given in pregnancy?

27-36 weeks' gestation

Contraindication for DTAP in infant

pt who experienced immediate anaphylactic rxn with previous doses

HIB is only given to children less than ____ years old

6

Yeast allergy is a contraindication for which vaccine?

Hep B

Newborns should receive their first dose of Hep B within when of birth?

first 24 hours of birth

HPV vaccine.. pt gets 2 doses if started series at age ____ or younger and 3 doses if started series at age _______ or older.

14 or younger- 2 doses
15 or older- 3 doses

Who should get the pneumococcal vaccine?

Smokers
ALL ADULTS 65+
immunocompromised
asthma
PSV23 in infants as well after PCV

PCV is only given to

infants

PSV23 is only given to

adults

Rabies vaccine post exposure prophylaxis is given which days?

days 0, 3, 7, 14 (RIG on day 0)

Don't give IgG serums within __________ months of a live vaccine.

3 months

IgG serums provide _______ immunity to infectious agents.

PASSIVE

Tuberculin PPD is checked at what level of skin?

intradermally

When is TB skin test read?

Read in 48-72 hours

Honey crusted lesions on the face

impetigo

Impetigo is often caused by which bacterial agents?
1.
2.

1. staphylococcus
2. streptococcus

Systemic abx are required for what type of impetigo? how many lesions?

5+; mod to severe

Topical tx for impetigo

Mupirocin 2%- 3x a day for 5-14 days

pt education for impetigo

wash hands; don't share towels or utensils, wash with antibacterial soap

Nasal MRSA treatment is which drug and which dose?

muciprocin; 1 g BID for 5 days (half dose for each nostril)

When do you add oral abx for impetigo?

more than 5 lesions or if no improvement in 2-3 days

Which oral abx would you add for impetigo if MRSA NOT suspected?

cephalexin, amox/cephalexin, dicloxacillin

If MRSA suspected for impetigo, which oral ABX would you add?

clindamycin or TMP/SMZ (bactrim)

Creams used to treat superficial fungal infections

azoles
nystatin

Tinea capitus treatment
1. oral option
2. biweekly shampoo w/ selenium sulfide

1. griseofulvin
2. biweekly shampoo w/ selenium sulfide, ketoconazole

Annular lesion with raised borders and clear center can signify which 2 conditions? treated how?

Tinea corporis and tinea cruris
Topical antifungal- imidazoles

Caused by dermatophytes E.floccosum, T.rubrum, C.albicans. treated how?

tinea pedis/ athlete's foot
Topical antifungal- imidazoles

fungal infection of the nail

onychomycosis

Antifungals can cause ________ problems!!!

LIVER

Griseofulvin may decrease efficacy of?

OCPs