Drug Therapy: Immune System

Module 2A Drug Therapy: Immune System

• Prepared by Mary Rose Gaughan. PhD, RN for D'Youville University, Summer 2024

Agenda

• Drug therapy for immune support and modification
• Drug therapy for infections
• Drug therapy for inflammation

Objectives

• Discuss and understand vaccination, immunoglobulins, and immunomodulators
• Describe drug therapy for infections and inflammation
• Describe medications utilized for bacterial, viral, and fungal infections
• Discuss ways to minimize emergence of drug-resistant microorganisms
• Discuss ways to increase benefits and decrease risk with antimicrobial drug therapy
• Identify prototype, action, use, contraindications, adverse effects, and nursing implications for medications treating infections

Focus Points and Reading Goals

• NSAID (Nonsteroidal Anti-Inflammatory Drugs) action and use
• Acetaminophen as an analgesic
• Differences of anti-arthritis agents
• Anti-gout agents
• Immune modulators, including stimulants and suppressants
• How vaccines and sera provide protection
• Classes of antibiotics
• Anti-virals for URI (Upper Respiratory Infections) and herpes
• Anti-fungal agents

Anti-Inflammatory Agents

• Relieve symptoms of the inflammatory process, which include swelling, fever, aches, and pains
• Block or alter the chemical reactions associated with the inflammatory response to stop signs and symptoms of inflammation

Salicylates

• Prototype: Aspirin (acetylsalicylic acid, ASA)
• Acts as an anti-inflammatory, antipyretic, analgesic, and prevents platelet aggregation
• Therapeutic actions inhibit prostaglandin synthesis, treating mild to moderate pain, fever, and inflammatory conditions
• Absorption occurs in the stomach
• Metabolized in the liver
• Excreted in urine
• Crosses the placenta and enters breast milk, so should not be used during pregnancy or lactation
• Should not be administered to children, due to risk of Reye's syndrome
• Known allergy, bleeding abnormalities, impaired renal function, chicken pox or influenza, pregnancy or lactation are all situations where one should avoid use
• Can cause nausea, vomiting, diarrhea, dyspepsia, heartburn, epigastric discomfort, blood loss, bleeding abnormalities, salicylism, dizziness, tinnitus, difficulty hearing, and mental confusion
• Interacts with many other drugs
• Assess for CNS/GI/bleeding effects before use
• Administer with food
• Monitor for toxicity
• Provide supportive care and ensure hydration

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Black box warning of CV and GI risks
• Choice depends on personal preference and patient's response
• Includes propionic acids, acetic acids, fenamates, oxicam derivatives, and COX-2 inhibitors
• Acetaminophen (Tylenol) is not an NSAID
• Prototypes include: Propionic Acids, Advil (ibuprofen), Aleve (naproxen), Acetic Acids, Voltaren (diclofenac), Toradol (ketorolac), Fenamates, Meclofenamate (meclomen), Oxicam Derivative, Mobic (meloxicam), Cyclooxygenase-2 (COX-2) Inhibitor, Celebrex (celecoxib)
• Therapeutic actions include inhibition of prostaglandin synthesis
• Blocks COX-1 and COX-2, stopping inflammation before signs and symptoms develop
• Rapidly absorbed in Gl tract, with peak effect in 1-3 hours
• Crosses the placenta and is found in breast milk
• Not recommended in pregnancy and lactation
• Do not use with allergy, CV dysfunction, HTN, peptic ulcer, known GI bleeding, pregnancy, or lactation or Caution with renal or hepatic dysfunction
• Adverse effects include nausea, dyspepsia, Gl pain, constipation, diarrhea, flatulence, GI bleeding, headache, dizziness, somnolence, fatigue, bleeding, platelet inhibition, HTN, bone marrow depression, rash, mouth sores, anaphylaxis, AKI
• Decreases diuretic effect with loop diuretics
• Decreases anti-hypertensive effect of beta-blockers
• Increases lithium toxicity and risk of bleeding with anti-coagulants/alcohol/glucocorticoids/ginger/ginkgo biloba
• Causes antiplatelet effects with ASA

Acetaminophen (Tylenol)

• Used to treat moderate to mild pain and fever
• Frequent drug for managing pain and fever in children
• Available OTC and found in many combination products
• Extremely toxic at high doses, resulting in severe liver toxicity that can lead to death
• Maximum daily dose is 4 g/day, lower for alcohol use or hepatic injury
• Acts directly on thermoregulatory cells in the hypothalamus to cause sweating and vasodilation for heat release, thus lowering fever
• Analgesic effect not identified
• Absorbed from Gl tract, peaking in 0.5-2 hours
• Contraindications include allergy, caution in pregnancy and lactation, hepatic dysfunction, chronic alcoholism, renal impairment, and ingesting alcohol while taking
• Causes headache, hemolytic anemia, renal dysfunction, skin rash, fever, and potentially fatal hepatotoxicity
• Acetylcysteine (Mucomyst) is the antidote
• Increases bleeding with oral anticoagulants, toxicity with chronic ethanol ingestion, and hepatotoxicity with seizure medications
• Assess for contraindications and allergy, monitor VS (vital signs) and adverse effects

Anti-arthritis Agents - Gold Compound (Chrysotherapy)

• Ridaura (auranofin) prototype
• Gold inhibits phagocytosis, reducing tissue destruction for rheumatic inflammatory conditions not responding to conventional therapy
• Administer with caution to those with sever diabetes, CHF, sever debilitation, renal/hepatic impairment, HTN, blood dyscrasias, recent radiation, hx toxic levels of heavy metals because it can be very toxic
• Absorbed at varying rates based on route
• Distributed throughout the body, concentrating in the HPA system, adrenal, and renal cortices
• Crosses placenta and enters breastmilk
• Causes stomatitis, glossitis, gingivitis, pharyngitis, laryngitis, colitis, diarrhea, GI inflammation, gold bronchitis, interstitial pneumonitis, bone marrow depression, vaginitis, nephrotic syndrome, dermatitis, pruritis, allergic reactions, renal toxicity causing proteinuria
• Do not combine with penicillamine, antimalarials, cytotoxic drugs, or immunosuppressive agents, as they can lead to severe toxicity

Anti-Arthritis Agents - Tissue Necrosis Factor (TNF) Blockers

• The prototype is Humira (adalimumab)
• Acts to decrease local effects of TNF, slowing the inflammatory response and associated joint damage for many types of arthritis
• Use with caution with renal/hepatic disorders, HF and latex allergies
• First class agent in progressive arthritis
• Must be given SQ (exception is infliximab – given IV) with slow onset
• Excreted primarily in tissues
• Long half-life (115 hours – 2 weeks)
• Serious to fatal infections and development of lymphomas/other cancers (BOXED WARNING)
• Screen and monitor patients
• Irritation at injection site is common
• Causes Demyelinating disorders (MS), myocardial infarction, heart failure & hypertension
• Do not use other immune suppressant drugs or live vaccines

Other Disease-Modifying Antirheumatic Drugs (DMARDs)

• Used when patients do not respond to other drug therapy
• Directly decrease pain in joints affected by arthritis
• Some antineoplastic drugs can modify disease process in rheumatoid arthritis
• See text for specifics

Antigout/Hyperuricemia Agents

• Treat gout disorders that are often characterized by elevated uric acid and urate crystal deposits in kidneys and joints = pain.
• Lopurin or Zyloprim (both are allopurinol) are the prototypes
• Lower blood uric acid levels
• Absorbed orally, with peak serum -1.5 hours, half life 1-2 hours
• Excreted renally and via feces
• Administer with caution to those with gouty attacks, that discontinue of rash or allergic reaction, hypersensitivity renal insufficiency, and are receiving thiazide medications or those that sensitive to colchicine use
• Cause hypersensitivity reactions, hepatic and renal dysfunction, N/V, transient increase in gout attacks
• Slows warfarin metabolism, increasing bleeding risk

Immune Modulators

• Immune Stimulants: stimulate exhausted immune system when fighting prolonged invasion or when fighting a specific pathogen or cancer cell
• Immune Suppressants: limit components of the immune system in cases of organ transplantation, autoimmune disorders, and in some cancers

Immune Stimulants - Interferons (IFNs)

• Naturally produced and released by human cells invaded by viruses
• Produced by recombinant DNA technology
• Large proteins known as cytokines
• Prototype: Intron-A (interferon alfa-2b)
• prevent virus particles from replicating and stimulate inside cells
• Inhibit tumor growth and replication
• Stimulate cytotoxic T-cells
• Enhance inflammatory response
• Well absorbed SC or IM
• Most have rapid onset, peak 3-8 hours, half life of 3-8 hours
• Broken down in liver and kidneys, primarily excreted through kidneys
• Known allergy or those with a risk of becoming pregnant should avoid; use contraceptives
• Causes Headache, dizziness, bone marrow depression, depression and suicidal ideation, photosensitivity and liver impairment
• Concurrent use with theophylline can lead to theophylline toxicity
• Use in multiple sclerosis (helps to reduce attacks), some cancers

Immune Stimulants - Interleukins

• Synthetic compounds that communicate between lymphocytes, stimulating cellular immunity and inhibiting tumor growth
• Prototype: aldesleukin (Proleukin)
• Activate cellular immunity, inhibit tumor growth, increase natural killer cells, cytokine activity, and circulating platelets
• Best for kidney and skin cancer applications
• Rapidly absorbed after injection (IV) with Primarily cleared via kidneys
• Cause sever drowsiness, respiratory difficulties, capillary leak syndrome, CNS changes that progress to coma, cardiac arrythmias with known allergy to drug or E.coli or who are likely to become/ are pregant
• Embryocidal and teratogenic in animal studies, not used in pregnancy, use barrier contraceptives
• May exacerbate cardio and neurotoxic effects and risk or if used with other antineoplastic medications

Immune Stimulants - Colony-Stimulating Factors

• Increase production of WBC's (White Blood Cells) and can reduce incidence of infection in patients with bone marrow suppression, decrease neutropenia associated with bone marrow transplant, chemotherapy, and help tx blood-related cancers
• Prototype: filgrastim (Neupogen) through IV or SC injection
• Peak in 2 hours IV or 8 hours SC with 220 minute half life
• Do not not use if pregant/lactating. Caution with bone marrow cancer or d/t stimulation effect on bone marrow
• Use in various blood-related cancer therapies
• Causes fatigue, alopecia, generalized weakness, alopecia, generalized pain and bone pain.
• Risk of splenomegaly, splenic rupture, leukocytosis, and thrombocytosis
• Avoid with a drug/ E.Coli allergies or with lithium and corticosteroids
• MonitorWBC counts and treat toxicity

Immune Suppressants - Immune Modulators

• Block cytokines responsible for inflammatory response, activity of lymphocytes = immune activity decreases, immune suppression
• Pregnancy can cause harm so proof is needed of if patient is not pregnant before beginning therapy
• Drug dependent Pharmacokinetics.

Immune Suppressants - T- and B-Cell Suppressors

• Therapeutic actions have different mechanisms
• Prototype: cyclosporine (Neoral)
• Block antibody production by B cells
• Inhibit suppressor and helper T cells
• Modify the release of interleukins and T-cell growth factor
• Use in Crohn disease, nephrotic syndrome, organ transplant for rejection
• Metabolized in the liver, excreted in bile
• The half-life for T- and B-cell Suppressors is 8.4 hours
• Can effect and increase risk of: Hepatic toxicity, renal toxicity, headache, edema, tremors, HTN, or secondary infections
• Can effect fertility and should not be used when patients intend on becoming pregnant
• Increase the risk of infections or and neoplasms and risk of nephrotocy
• Do not combined with hepatotoxic & nephrotoxic drugs

Immune Suppressants – Interleukin Receptor Antagonist

• Only one available, anakinra (Kineret) of E.coli derived medication
• Use in rheumatoid arthritis, cryopyrin-associated periodic syndromes, Familial Mediterranean Fever
• Avoid in lactating/ pregnant patients to to possible affects for infants
• Use with caution in immunosuppressed patients/ renal impairment due to the likely adverse reactions
• Causes Increased risk of and allergic reactions infections, and has many drug to drug interactions

Immune Suppressants - Monoclonal Antibodies

• Designed to be attracted to a specific target (specific cell, virus, bacteria, or antibody) to to treat cancer, types of arthritis, MS, other diseases
• Prototype: bevacizumab (Avastin)
• Rapidly broken down in Gl tract, processed by the body like naturally occurring antibodies
• Used for breast cancer treatment
• Cannot take if allergic to murine produces or who are likely to become pregnant. May cuase fluid obver load
• May cause side effects to heart and other areas

Vaccines

• Best source is Centers for Disease Control
• Artificially stimulating active immunity by exposing the body to weakened or less-toxic with disease-causing organisms that include attenuated bacteria and chemically inactivated microorganism and toxins
• Vaccines can be specific to age and region

Actions & Indication

• It is thought that active immunity is stimulated in those at a high risk for deveoping a disease for long-term immunity
• This acts as a process with the presence of similar endogenous antibodies from the body & may cause severe illness or other negative side effects/ sensivities

Immune Sera:

• Is a passive artificial immunity that produces preformed antibodies to an antigen thats within the same immune
• Treats exposures to Antigens

Actions & Indications

• Aids infections by pathogens, toxins, or venom
• May be contraindicated to severe reactions

Antibiotics:

• Functions by decreases pathogen population & resistance for effectivly the human with immunity
• Can be caused by superinfections or be bacteriasidic

Actions & Indications

• Aminoglycosides: Treat infections caused by gram-negative bacilli

• Carbapenems: Broad against infections Fluroquinolones: Enter cell through DNA

• Are mostly absorbed by injections

Cephalosporins Actions

• Can be bacteriocidal dependent on different drugs & doses
• Interfer with cell to to treat infections.

Penicillins Actions

• Treat major effects while building cell structure
• May case contraindications to kidney health or other conditions

Lipoglycopeptides

• Are semi-synthetic
• Treat skin or other adults structures

Macrolides:

• Are infections that are suppressed by other mechanisms and can happen when the digestion

Anti-virals

• The most effective types need host cells to multiply as they can destroy the host when treating illnesses and the effects include Influenza

Antifungal Agents indication:

• Treat a variety of mucus membranes and skin with tinea infections or and and alter the cells to local treatment
• Are made with zole and Canidine with consideration to each patients

The study notes cover a wide range of information about how drug therapies are utilized for the immune system, including treatment for all different kinds of areas of viral infections.

Explore drug therapies for immune support, infections, and inflammation, including vaccines, immunoglobulins, and immunomodulators. Learn about medications for bacterial, viral, and fungal infections. Discuss minimizing drug resistance and maximizing benefits with antimicrobial therapy.