Autoimmunity- Answers To Fill In Blanks MEDS PDF

*NSAIDS and Steroids: BOTH Relieve pain and reduce swelling* ***NSAIDs**: relieve pain and reduce swelling (minor inflammation), do not reduce long term effects of RA. Weight risk vs. benefits r/t SE's.* *should be avoided in patients that have* HTN, *CAD, or any heart issues d/t increased risk of...

*NSAIDS and Steroids: BOTH Relieve pain and reduce swelling* ***NSAIDs**: relieve pain and reduce swelling (minor inflammation), do not reduce long term effects of RA. Weight risk vs. benefits r/t SE's.* *should be avoided in patients that have* HTN, *CAD, or any heart issues d/t increased risk of thrombotic events, MI, and stroke..* *Also should avoid in those taking steroids b/c of inc risk of GI bleed.* Ex. Ibuprofen, Celecoxib(Celebrex) **Steroids**: Strong anti-inflammatory effects, generally used for pts whose function is severe debilitated by RA. Ex: Methylprednisolone, Prednisone Work quickly to reduce symptoms. Goal: is to use the lowest dose possible for symptom relief prefer 10mg or less/day Prednisone given in flareups decrease inflammatory and immune response by decreasing WBC response. SE's: fluid retention which can lead to increased BP fluid and electrolyte imbalances, moon face, , decreased immunity with can lead to infections, hyperglycemia which can lead to diabetes, weight gain, bone loss which can lead to osteoporosis, excess hair (hirsutism) is also a long term effect. Prolonged use can also cause cataracts. Therefore: *not (usually) used for long term therapy* *Used with caution with those with HTN. Also use with caution in those with hypothyroid b/c prevents conversion of T4 to T3 (active thyroid hormone)!* *RA causes a decrease in bone density, which can lead to osteoporosis. Bone loss is more likely in people who are inactive.* ***The use of steroid medications, such as prednisone, further increases the risk of bone loss**, especially in women who have been through menopause.* Recommend adequate Calcium and Vit D supplements Side note: Intra-articular corticosteroids are effective for controlling local flares in a joint w/o changing overall drug regimen of steroids **[-Immunosuppressants: \*\*\*]** Good news: Helps body to stop attacking itself! But [B](https://www.everydayhealth.com/drugs/hydroxychloroquine)ad news = bone marrow **suppression** = high risk for infection and \*\*\*\* high risk for bleeding \*\*\*\* **DMARDs -- disease modifying antirheumatic drugs**, initial treatment: immunosuppressant!! How are DMARDs similar to NSAIDS?? improve s/s of inflammation.... Differ?? But only DMARDS can alter the disease course These drugs Reduce inflammation (which therefore reduces pain), reduce joint damage, preserve function, enabled ADL ability, reduce mortality rates and enhance quality of life **Early treatment with a DMARD has become standard of care in treating RA & Lupus**: so Almost every pt should have a DMARD prescribed! Two types: Non-biologic DMARD and Biologic DMARD [-Nonbiologic DMARD]: composed of small molecules made from chemicals in a lab. They SUPPRESS the immune system. (PILLS) Ex Hydroxychloroquine and Methotrexate [-Biologics DMARDS]: are large molecules produced in living cells. They BLOCK specific parts of the immune system (ex Tumor Necrosis Factor inhibitors block an inflammatory protein called TNF) (INJECTIONS usually) Unlike conventional DMARDs, which can take a month or more to begin working, biologics and kinase inhibitors tend to work more rapidly, within two weeks for some medications and within four to six weeks for others. Ex *Etanercept (Enbrel*): SQ, Infliximab (Remicade) and *Adalimumab (Humira*) [Nonbiologic DMARDS:] -**Hydroxychloroquine** (Plaquenil) -- anti-malarial Decreases inflammation and fatigue Will see increase energy- but takes several MONTHS to get to therapeutic level MAJOR adverse Effects -Retinal Damage: must have eye exam every 6-12mo Hyyyyyyyyy-droxy: EYES. Hyyyyyy = eyes, Benefits: helps [prevent lupus flares](https://www.everydayhealth.com/lupus/preventing-flares.aspx), minimizes joint inflammation, and controls fever, fatigue, pleurisy (inflammation of the sac surrounding the lungs), and [pericarditis](https://www.everydayhealth.com/pericarditis/guide/) (inflammation of the lining around the heart). The drug is also "the backbone of therapy" for most [skin rashes associated with lupus](https://www.everydayhealth.com/lupus/how-to-identify-lupus-rash-and-other-skin-symptoms-of-the-condition/) Need for osteoporosis meds (Vit D and Calcium)?? NO b/c not affect bones!! Safe during pregnancy?? Actually, the safest DMARD during pregnancy -***Methotrexate*** Commonly used drug for Lupus and RA to decrease inflammation and fatigue. How does is work? Is stops folic acid metabolism which therefore stops cellular reproduction in the fastest replicating cells which are found where?? In bone marrow, immune system and fetus. So again high risk for infection and bleeding. But also NO PREGNANCY!! \*\*found conflicting info of folic acid supplementation so recommend consulting with MD Mainstay of therapy for RA b/c it's effective and relatively inexpensive. SLOW acting: 4-6 weeks to control joint inflammation **MethOtrexate**: NO pregnancy, NO live vaccines NO large groups/sick people. No razors/hard brushing teeth (huge bleed risk) NO alcohol bone marrow suppression = low platelet which means = high risk of bleeding Thrombocytopenia = platelets under 150,000. Under 150 is risky, under 50 is very iffy! Must report bleeding! Includes: Bleeding gums Petechiae (bleeding under skin) Purpura (purple spots on skin) Melena (black tarry stool) Hematemesis (vomiting blood) Neutropenia = low WBC count so causes = infections No crowds NO live vaccines including varicella (chickenpox), measles, mumps, rubella (MMR), oral polio, yellow fever, BCG, and oral typhoid A fetus has quickly replicating cells which could = causes baby death Do NOT get pregnant. Memory trick with MethOtrexate is Meth-NO-trexate! No razors or hard brushing teeth No crowds/sick ppl No live vaccines No pregnant No alcohol because of liver toxicity Time to see benefits: May need 4-6 weeks before change is noted and possibly 6 months to experience full benefits If no response after 2 months: may add a biologic *-BOTH Azathioprine (Imuran) and Cyclosporine: are also DMARDs* *Common side effect for Cyclosporine: **Gingival hyperplasia -** does not need to be reported* *Patient teaching: no grapefruit juice (true for 99% of all drugs!)* [Biologic DMARD: ] ***Biologic response modifiers* a**re the **newest DMARDs** being tried on RA. Unlike conventional DMARDs, which can take a month or more to begin working, biologics and kinase inhibitors tend to work more rapidly, within two weeks for some medications and within four to six weeks for others. Extremely expensive. High risk for developing impaired immunity and subsequent infection b/c these neutralize biologic activity of immunity cells to decrease immune response and inflammation. Have to have negative TB test before starting. **Must have negative PPD test to start!** **And test yearly!** Must **avoid live vaccines** once start. -Ok to get vaccines that are INACTIVATED: like flu vaccine -NOT ok to get live vaccines: varicella (chickenpox), measles, mumps, rubella (MMR), oral polio, yellow fever, BCG, and oral typhoid Must **stay away from ppl with infections, large crowds**. Key Point: **REPORT** elevated WBC Report fever over 100.4 (38C) since suppressed system with a fever can be very bad Pt Education: **Must have negative TB test** to start medication (bc can be reactivated) If + TB, but be started on TB meds before starting Infliximab Again, no LIVE vaccines Avoid infection risks: large crowds, sick ppl **Contraindication**: Can NOT start medication if have chronic, recurring or recent infection (ex pt on an antibiotic for recurrent infection) Elevated CRP is NOT most important lab; to be expected Ex for Lupus: Belimumab Monoclonal antibody produced by recombinant DNA technique that specifically binds to B-cell stimulator protein and inactivates it. WHY HELPFUL? Less autoantibodies created to attack self. Monitoring during infusion and up to 2 hours after infusion is required for possibly anaphylaxis or reaction. Ex for RA: TNF Inhibitors: Etanercept (Enbrel), Infliximab (Remicade) and Adalimumab (Humira) Infliximab (Remicade): IV infusion, side effects increase with higher dose. *Adalimumab (Humira*): SQ- less joint stiffness, swelling, better mobility, carefully monitoring for immunosuppression *Others included in your book and chart page 1022.* Tumor Necrosis Factor (TNF) is an inflammatory protein- TNF Inhibitor blocks it therefore less inflammation -Why are TNF inhibitors not given to those with Lupus?? Some pts taking this drug develop antinuclear antibodies and cases of drug-induced Lupus are reported and/or worsening of disease. So not *usually* given for lupus. *Use of **opioids are discouraged** bc they do not affect inflammation, which is the pain stimulator in RA.* *FOR RA ONLY:* ***Plasmapheresis** combined with DMARDs; plasma exchange in hospital using a machine similar to dialysis, option with severe life-threatening disease* \* * ***Surgery**: End stage RA -- severe joint damage and loss of function. LAST resort. TJA (total joint arthroplasty ie knee replacement) is the most common surgery.* *Synovectomy -- removed inflamed synovium* ***CAM** complimentary alternative medicine:* *Studies have shown benefits: mind-body techniques (prayers, meditation), Visualization/guided imagery (relaxation), martial arts (yoga, tai chi) , touch therapy (massage), and herbs/supplements (glucosamine, green tea)*