SYSTEMIC STEROIDS
Q: What are some roles that cortisol play in our body?
A) Reduce inflammation
B) Maintain Blood Pressure
C) Maintain immune functions
D) Increase blood glucose levels
E) All of the above
Key: E
Cortisol has many additional roles in the body including:
Manages how your body uses carbohydrates, fats, and proteins
Boosting energy
Regulating metabolism
Q: What is wrong with this statement?
Rheumatoid Arthritis is an acute autoimmune disorder that primary affects joints.
Key: It is not acute, it is a chronic progression disorder
Rheumatoid Arthritis is a chronic systemic disease that affects the joints, connective tissues, muscle, tendons, and fibrous tissue.
Q: Who does lupus primarily affect?
A) Males
B) Females
Key: Females
Ratio of female to male = 10:1
Specifically younger women (age:15-45) more common in women of African-American and Asian decent
Q: Which category of symptoms match correctly for MS?
A) Primary symptoms- Urinary tract infection from urinary retention, shallow breathing, bone density
B) Secondary symptoms- bladder and bowel movements (frequent urination, trouble emptying bladder fully), clumsiness
C) Tertiary symptoms- Cannot do well in current occupation, more antisocial than before, depression
Key: C
A) These are secondary symptoms. UTI can result from urinary retention. You can have shallow breathing due to muscle weakness from being inactive (trouble walking and fatigue) and less bone density as well.
C) These are primary symptoms. Results from direct damage to myelin.
Correct order
Q: What are some medical conditions that we may use corticosteroids for?
A) Rheumatoid Arthritis
B) Uncontrolled hyperglycemia
C) Adrenal Insufficiency
D) A and C
E) All of the above
Key: D
The answer cannot include B due to:
One of their side effects is to increase blood glucose (sugar) since these drugs promote glucose production in the liver and reduce the sensitivity of the cells to insulin. Consequently, glucose accumulates in the blood and can cause a rise in blood sugar levels.
A is correct because: Steroids are commonly used in RA flares and should be used at the lowest dose and for the shortest duration possible. They are commonly used to bridge the time until treatment with DMARDs is effective.
Secondary Adrenal Insufficiency: The mainstay of treatment is corticosteroid replacement therapy with careful monitoring. This treatment is to replace endogenous steroids that the adrenal gland is not producing in adequate amounts. Disease example: Addison’s disease
You can also use steroids for Lupus and MS
Q: Typical Rheumatoid Arthritis symptoms may include:
A) Bilateral, symmetrical disease
B) Rheumatoid factor is negative
C) Morning Stiffness for at least one hour
D) Disease distribution is local
E) A, C
F) All of the above
Key: E
Joint movement is bilateral symmetrical so on both sides of the body vs. Osteoarthritis which is unilateral (on one side of body) (neck, back, hip) rheumatoid (wrists, hands, feet)
Rheumatoid factor is frequently positive
Rheumatoid factors are proteins produced by your immune system that can attack healthy tissue in your body
D: it is not local it is systemic so throughout the body.
Q: Which drug(s) can cause Drug-Induced Lupus Erythematosus?
A) Methimazole
B) Methyldopa
C) Quinidine
D) Procanamide
E) All of the above
Key: E
All of them can cause DILE.
Complete list of drugs:
Methimazole - Antithyroid
Propylthiouracil - Antithyroid
Methyldopa - Antihypertensive
Minocycline - Antibiotic
Procanamide - Antiarrhythmic
Hydralazine - Vasodilator
Anti-TNF agents – anti-inflammatory
Terbinafine - Antifungal
Isonazid - Antibiotic
10)Quinidine - Antiarrhythmic and Anti-parasite
Usually DILE resolves within weeks after drug discontinuation.
Q: Which of the following tests may be used to diagnose MS?
A) MRI
B) Spinal tap
C) Evoked potential tests
D) Differential diagnosis
E) B, D
F) All of the above
Key: F
MRI: which can reveal areas of MS (lesions of active inflammation) on your brain and spinal cord.
Spinal tap: This sample can show abnormalities in antibodies that are associated with MS. A spinal tap can also help rule out infections and other conditions with symptoms similar to MS.
Evoked potential tests: Record the electrical signals produced by your nervous system in response to stimuli. Electrodes measure how quickly the information travels down your nerve pathways.
In most people with relapsing-remitting MS, the diagnosis is fairly straightforward and based on a pattern of symptoms consistent with the disease and confirmed by brain imaging scans, such as MRI.
Q: How does Cushing syndrome develop?
Key: It can develop when the adrenal gland produces too much cortisol, or when exogenous steroids are taken in high doses and the amount of cortisol produced is higher than normal for a long period of time. Long term use of steroids can also contribute to Cushing’s syndrome.
Q: What two laboratory tests are specific in diagnosing RA (Rheumatoid Arthritis)?
A) ESR (erythrocyte sedimentation rate)
B) ACPA (Anti-Citrullinated peptide antibody)
C) CRP (C-reactive protein)
D) RA (rheumatoid Factor)
E) A and D
F) B and D
Key: F
Generally nonspecific means many other conditions can increase these biomarkers
ESR (erythrocyte Sedimentation Rate) is non-specific, determines rate of inflammation
CRP (C-reactive protein) General non-specific. This protein binds to damaged tissue and this test is used to determine detect inflammation.
ACPA (Anti-Citrullinated peptide antibody, highly specific) target citrullinated proteins which have arginine residues due to a conversion to citrullinate; this conversion makes it foreign to the body and that is why our body basically attacks itself in areas of where citrullinated proteins are located, like the joints.
Rheumatoid Factor- more specific present in 60-70% of patients with RA so in general if this biomarker is positive, the patient likely has RA.
Which drug (s) is FDA approved for Lupus?
A) Cyclophosphamide
B) Hydroxychloroquine
C) Azathioprine
D) Belimumab
E) B, D
Key: E
Hydroxychloroquine (DMARD) has been approved and used for years. The drug appears to work by stopping immune proteins called autoantibodies from triggering the immune response that causes these diseases.
Belimumab (monoclonal antibody) is recently approved and new.
Belimumab: reduces the activity of B-cell mediated immunity and the autoimmune response
Q: Which drugs can be considered first line therapy for relapsing forms of MS ?
A) Interferon beta-b (betaseron)
B) Glatiramer Acetate
C) Natalizumab
D) Finoglimod
E) A, B
F) All of the above
Key: E
High dose IFNB 1-a and GA are the preferred options among established injectable therapies
Beta interferon 1a (available under the trade name Avonex®) – given by injection into a muscle (intramuscular) once a week using a pre-filled syringe.
Beta interferon 1a (Rebif®) – given by injection under the skin (subcutaneously) three times a week using a pre-filled syringe.
Beta interferon 1b (Betaferon® and Extavia®) – given by injection under the skin (subcutaneously) every other day. The injection needs to be prepared by mixing the ingredients before drawing it up in a syringe.
Glatiramer acetate (Copaxone®) – given by injection under the skin (subcutaneously) once a day using a pre-filled syringe.
Second line: Alemtuzumab, Finoglimod (oral immunomodulator) and Natalizumab
All these treatments are to reduce relapses.
Q: What can happen when we suddenly stop the use of corticosteroids?
Key: It can lead to adrenal suppression- which can have an outcome of adrenal crisis and death. Addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium.
Patients can experience adrenal suppression (a form of adrenal insufficiency) which caused by abrupt withdrawal of chronic glucocorticoid administration.
Q: What is the recommended 1st line initial therapy for RA?
A) Hydroxychloroquine
B) Leflunomide
C) Methotrexate
D) Sulfasalazine
Key: C Methotrexate
A – If individuals have prior liver disease, alcohol abuse, or if they cannot tolerate methotrexate or leflunomide Hydroxychloroquine is the go to. Much less adverse events, much less monitoring. Can be used in combination with MTX
B – Leflunomide: It has properties of immunosuppression and antiinflammation
Effects are similar to MTX so it can be substituted. So if a patient cannot tolerate MTX for reasons like myelosuppression (A condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets.) use Leflunomide
D: Primarily anti-inflammatory less of an immunosuppression can be used in combination with MTX as an add on if not wanting to use hydroxychloroquine
Q: How long may it take to see maximal benefit from treatments such as immunosuppressants or cytotoxic agents to control disease?
A) 3 months
B) 12 months
C) 1 month
D) 6 months
Key: D
Q: Which MS medication is safe for pregnant women?
A) Interferon beta-b (betaseron)
B) Teriflunomide
C) Glatiramer Acetate
D) Fingolimod
E) Dalfampridine
F) None of the above
Key: Glatiramer Acetate, studies show safety
Preferred agent for pregnant women
A) Interferons- in one study- increased risk of fetal loss
B) Contraindicated
C) Correct answer
D) Not recommended
E) Not clear
Q: Knowing that long term use of steroids can cause Cushing’s syndrome, what are some ways to reduce systemic steroid risks?
Key: All of the above
This will decrease Cushing’s Syndrome
So the drug stays local
High systemic absorption can cause potential adverse effects and so for a gut condition for example inflammatory bowel disease it would be better to use steroids that have low systemic absorption. Examples would include budesonide and beclomethasone dipropionate. After intestinal absorption, these drugs are promptly and efficiently inactivated by the liver, so that only inactive molecules reach the systemic circulation.
For asthma, a inhaled corticosteroid would mostly stay in lungs and not affect other areas of the body
For these patients immunosuppression is key and so they may need to stay on low dose corticosteroids because they will need it for maintenance therapy.
Q: Patients who are using Adalimumab, Etanercept and Golimumab should be cautioned regarding live vaccines. Provide a reason for why you may think the answer is either A or B.
A) True
B) False
Key: A (true)
Reason: Because patients on these medications should not be taking any live vaccines since they work by blocking the immune system, thus lowering ones ability to fight infections. This can increase the chances of getting serious infections.
Q: Which organ injury develops in over 50% of patients with SLE?
Key: Kidney
AKA Lupus Nephritis
Lupus nephritis occurs when lupus autoantibodies affect structures in your kidneys that filter out waste. This causes kidney inflammation
-Can cause high blood pressure.
Q: What are some goals we should keep in mind when managing patients with MS?
Key: It is important to keep in mind the 4 main goals of MS management:
(1) modifying/reducing relapses and delaying progression to disability
(2) treating relapses (pharmacological)
(3) managing symptoms
(4) maintaining an acceptable quality of life.