Immunosuppressants and Immunity

• Immunosuppressants are administered to decrease an undesirable immune response
• Autoimmune disorders occur when the immune system cannot distinguish between self and non-self
• Asthma and psoriasis are examples of conditions where immunosuppressants may be used.

Types of Drugs Used to Decrease Immunity

• Cytotoxic immunosuppressive agents, conventional antirejection agents, antibody preparations and tumor necrosis factor-alpha-blocking agents are types of drugs used to decrease immunity
• Examples of cytotoxic immunosuppressive agents are methotrexate and cellcept
• Cyclosporine and tacrolimus are examples of conventional antirejection agents
• Omalizumab is an example of antibody preparations
• Infliximab and adalimumab are examples of tumor necrosis factor-alpha-blocking agents

Mycophenolate Mofetil (CellCept)

• Used to prevent rejection of kidney, heart or liver transplants, and to treat lupus, rheumatoid arthritis, and IBD
• Caution with renal and liver patients at risk of toxicity, multiple interactions with herbal supplements and risk during pregnancy
• It's important to monitor CBC, serum levels, and liver & kidney labs
• Administered once a week for rheumatoid arthritis or psoriasis and lifelong for transplants
• Take on an empty stomach at a regular time each day and wear gloves
• Don't take with grapefruit juice
• Adverse effects include GI issues, nephrotoxicity, hepatotoxicity, risk for infection, and increased risk of malignancy
• A negative pregnancy test is needed due to the risk of fetal loss & malformations.

Methotrexate

• Used to treat cancer and autoimmune disorders such as rheumatoid arthritis and psoriasis
• It can be combined with cyclosporine for graft-versus-host disease (GVHD) after bone marrow transplant
• Caution for those with renal conditions and hepatic impairment, and during pregnancy
• Monitor CBC and kidney and liver function
• Hydrate and keep accurate dosage records of all dates and times
• Take with food and wear gloves
• Adverse effects include GI issues, hepatotoxicity, nephrotoxicity, increased risk for malignancy, and oral mucositis
• It can cause liver disease.

Cyclosporine (Gengraf)

• Used to prevent transplant rejection
• Caution with renal and liver patients and during pregnancy
• Monitor weight-based dosing, liver & kidney labs, serum levels of medicine, and lipid levels
• Initiate several hours before transplant and administer at the same time of day
• Intravenous onset of action is rapid, then switch to oral administration
• Give with water, orange, or apple juice, but not in a styrofoam cup
• Wear gloves during administration
• Side effects include GI upset, acute nephrotoxicity, acute hepatotoxicity, and increased risk for malignancy
• It causes hypertension and nephrotoxicity
• Long-term use increases the risk of infections and certain malignancies.

Tacrolimus (Prograf)

• Used to prevent transplant rejection
• May allow corticosteroids to be tapered down to alleviate side effects
• Use caution in patients with renal and hepatic toxicity, and with severe allergic reaction with I.V. administration
• Monitor liver/kidney labs, serum medicine levels, give hours before transplant at the same time of the day
• Intravenous action is rapid, then switch to oral administration
• Give with water, orange or apple juice, but not in a Styrofoam cup
• Wear gloves
• Side effects include GI upset, Acute nephrotoxicity and hepatotoxicity, increased malignancy risk.
• Causes hypertension and nephrotoxicity
• Long term use increases risk of infection and certain malignancies

Omalizumab (Xolair)

• Reduces sensitivity to allergens related to hypersensitivity and can be used for asthma
• Precautions with dose/volume calculations
• SubQ administration must be in healthcare setting with rescue equipment
• Use no more than one vial injected into one site at a time or two sites when the dose is high, every 4-6 weeks
• Adverse effects include local reaction at the injection site, headache, nausea, fatigue, watch for bronchospasm or angioedema after administration

Infliximab (Remicade)

• It's used to treat rheumatoid arthritis and Crohn's disease
• It must be discontinued if severe reactions occur
• Only administer in settings with life-saving equipment for a potential hypersensitivity reaction
• Negative effects include GI issues like nausea vomiting and diarrhea, formation of autoimmune antibodies which worsens the existing autoimmune issue, dyspnea, hypotension and urticaria, may aggravate heart failure
• There is a risk for serious infections.

Adalimumab (Humira)

• Used to treat rheumatoid arthritis
• It's contraindicated with live vaccines
• Stop administration if the patient has a serious infection or sepsis
• Watch for signs/symptoms of TB
• Negative effects include nausea, headache, skin rash, and upper respiratory tract infections

Nurse's Role

• When a nurse is caring for a patient taking immunosuppressant drugs, the most critical information involves decreasing the risk of infection.