CSP Clinical Management: Immunology 2 — Questions and Answers
Question 1: Which screening test is required before initiating adalimumab therapy?
- Serum ferritin
- Latent tuberculosis test (IGRA or TST) (Correct answer)
- Antinuclear antibody titer
- Thyroid-stimulating hormone
Correct answer: Latent tuberculosis test (IGRA or TST)
TNF inhibitors carry a boxed warning for serious infections including TB reactivation, so latent TB screening is required before starting.
Question 2: A patient with psoriasis also has active Crohn's disease. Which drug class should generally be avoided?
- IL-23 inhibitors
- TNF inhibitors
- IL-17A inhibitors (Correct answer)
- IL-12/23 inhibitors
Correct answer: IL-17A inhibitors
IL-17 inhibitors such as secukinumab and ixekizumab have been linked to new onset or worsening of inflammatory bowel disease.
Question 3: The ORAL Surveillance trial led to expanded boxed warnings for tofacitinib. What did they add?
- Hepatotoxicity and pancreatitis
- Hypertension and hyperkalemia
- Optic neuritis and seizures
- MACE, thrombosis, malignancy, and mortality (Correct answer)
Correct answer: MACE, thrombosis, malignancy, and mortality
Compared with TNF inhibitors in older RA patients with cardiovascular risk factors, tofacitinib showed more MACE, thrombosis, malignancy, and death.
Question 4: Why is certolizumab pegol often preferred for patients with immune-mediated disease during pregnancy?
- It lacks an Fc region, so very little crosses the placenta (Correct answer)
- It is given orally
- It is not an immunosuppressant
- It has the shortest half-life of all biologics
Correct answer: It lacks an Fc region, so very little crosses the placenta
Without an Fc portion, certolizumab is not actively transported across the placenta by the neonatal Fc receptor.
Question 5: Ustekinumab exerts its effect by targeting which structure?
- IL-23 p19 subunit only
- IL-17A
- Shared p40 subunit of IL-12 and IL-23 (Correct answer)
- IL-6 receptor
Correct answer: Shared p40 subunit of IL-12 and IL-23
Ustekinumab binds the p40 subunit shared by IL-12 and IL-23, blocking both cytokines.
Question 6: Which vaccine is contraindicated for a patient currently receiving a TNF inhibitor?
- Recombinant zoster vaccine
- Measles, mumps, rubella (MMR) (Correct answer)
- Inactivated influenza vaccine
- Pneumococcal conjugate vaccine
Correct answer: Measles, mumps, rubella (MMR)
Live vaccines such as MMR are contraindicated during biologic immunosuppression because of the risk of vaccine-strain infection.
Question 7: Infliximab is commonly given with methotrexate in rheumatoid arthritis mainly to do what?
- Reduce formation of antidrug antibodies (Correct answer)
- Prevent infusion-site extravasation
- Replace TB screening
- Lower the infliximab dose to subcutaneous levels
Correct answer: Reduce formation of antidrug antibodies
Infliximab is chimeric, and adding methotrexate lowers immunogenicity, which helps keep the drug effective.
