CSP Clinical Management: Immunology 5 — Questions and Answers
Question 1: Upadacitinib is best described as which type of agent?
- Pan-JAK inhibitor equally potent on JAK1-3 and TYK2
- TYK2 allosteric inhibitor
- Selective JAK1 inhibitor (Correct answer)
- BTK inhibitor
Correct answer: Selective JAK1 inhibitor
Upadacitinib preferentially inhibits JAK1, but it still carries the class boxed warnings for JAK inhibitors.
Question 2: A patient with a history of multiple sclerosis is being considered for psoriatic arthritis therapy. Which class warrants the most caution?
- IL-23 inhibitors
- TNF inhibitors (Correct answer)
- PDE4 inhibitors
- IL-17 inhibitors
Correct answer: TNF inhibitors
TNF inhibitors have been linked to new or worsening demyelinating disease and should be avoided in MS.
Question 3: Belimumab is used in systemic lupus erythematosus to inhibit which target?
- B-lymphocyte stimulator (BLyS/BAFF) (Correct answer)
- CD20
- Type I interferon receptor
- Complement C5
Correct answer: B-lymphocyte stimulator (BLyS/BAFF)
Belimumab binds soluble BLyS, which reduces B-cell survival and differentiation.
Question 4: What is the standard secukinumab dosing for adult plaque psoriasis?
- 150 mg every 8 weeks
- 45 mg at weeks 0 and 4, then every 12 weeks
- 300 mg once, then as needed
- 300 mg at weeks 0, 1, 2, 3, and 4, then every 4 weeks (Correct answer)
Correct answer: 300 mg at weeks 0, 1, 2, 3, and 4, then every 4 weeks
Secukinumab is loaded weekly for 5 doses and then given every 4 weeks as maintenance.
Question 5: A patient is HBsAg-negative and anti-HBc-positive, and is about to start a TNF inhibitor. What is the best approach?
- Never start any biologic
- Give hepatitis B vaccine and proceed without monitoring
- Monitor HBV DNA and ALT or give antiviral prophylaxis per hepatology guidance (Correct answer)
- Check anti-HCV only
Correct answer: Monitor HBV DNA and ALT or give antiviral prophylaxis per hepatology guidance
A resolved HBV infection can reactivate under immunosuppression, so monitoring or prophylaxis is recommended.
Question 6: A Crohn's patient loses response to infliximab maintenance. What is the next evidence-based step?
- Check infliximab trough level and antidrug antibodies (Correct answer)
- Switch right away to etanercept
- Stop all therapy for 6 months
- Double the methotrexate dose only
Correct answer: Check infliximab trough level and antidrug antibodies
Reactive therapeutic drug monitoring tells apart low exposure (dose escalation), immunogenicity (switch within class), and mechanistic failure (switch class).
Question 7: Before starting tofacitinib, which vaccine is recommended because of increased infection risk with JAK inhibitors?
- Live zoster vaccine during therapy
- Yellow fever vaccine
- Oral typhoid vaccine
- Recombinant zoster vaccine (Correct answer)
Correct answer: Recombinant zoster vaccine
JAK inhibitors raise the risk of herpes zoster, and the non-live recombinant zoster vaccine is preferred before or during therapy.
CSP Clinical Management: Immunology 5
Upadacitinib is best described as which type of agent?