Patients with various rheumatologic and autoimmune conditions are frequently managed with long-term immunosuppressive therapies, each carrying a unique adverse effect profile. Match each clinical scenario describing an adverse drug effect or mandatory screening requirement to the corresponding disease-modifying antirheumatic drug (DMARD) or immunosuppressant.
- A 45-year-old woman treated for rheumatoid arthritis develops painful oral ulcers, nausea, and macrocytic anemia.Methotrexate
- A 32-year-old woman with systemic lupus erythematosus is instructed to undergo annual optical coherence tomography and visual field testing.Hydroxychloroquine
- A 55-year-old man treated for severe systemic vasculitis presents with gross hematuria and bladder mucosal telangiectasias.Cyclophosphamide
- A 50-year-old man with ankylosing spondylitis develops fever, night sweats, and a cavitary lung lesion shortly after starting biologic therapy.Infliximab
- A 40-year-old woman on maintenance therapy develops newly elevated blood pressure, hyperuricemia, and swollen, bleeding gums.Cyclosporine
Answer
The correct pairings are: oral ulcers and macrocytic anemia with Methotrexate; mandatory retinal screening with Hydroxychloroquine; hemorrhagic cystitis with Cyclophosphamide; reactivation tuberculosis with Infliximab; and gingival hyperplasia with Cyclosporine.
Disease-modifying antirheumatic drugs (DMARDs) and immunosuppressants possess distinct side effect profiles. Methotrexate acts as a folate antimetabolite, frequently causing toxicity in rapidly dividing cells such as stomatitis, myelosuppression (macrocytic anemia), and hepatotoxicity. Hydroxychloroquine can bind to melanin in the retinal pigment epithelium, causing irreversible bull's-eye maculopathy; thus, baseline and annual ophthalmologic screening is mandatory. Cyclophosphamide is metabolized by the kidneys into acrolein, a toxic metabolite that concentrates in the bladder, leading to hemorrhagic cystitis and increasing the risk of transitional cell carcinoma. Infliximab, a TNF-alpha inhibitor, impairs macrophage function and the maintenance of granulomas, significantly increasing the risk of reactivating latent granulomatous infections like tuberculosis. Cyclosporine, a calcineurin inhibitor, is well-known for causing afferent arteriolar vasoconstriction (leading to nephrotoxicity and hypertension) as well as gingival hyperplasia and hyperuricemia.
Step-by-Step Solution
Key Concept
Adverse effect profiles and screening requirements of common rheumatologic immunosuppressants
Estimated Time:2m 0s