Nonbiologic csDMARDs: Immunosuppression and Medications

• Nonbiologic csDMARDs are antimetabolite medications suppressing the immune system by interfering with B and T lymphocyte activity.

Prototype and Medications

• Methotrexate serves as the prototype for csDMARDs.
• Other medications include leflunomide, hydroxychloroquine, and sulfasalazine.
• DMARDs are used to suppress the immune response in autoimmune disorders like RA, where the client's antibodies attack their own tissues.

Expected Pharmacologic Action

• The primary action of nonbiologic DMARDs is immunosuppression.
• They can slow or stop the progression of RA due to their immunosuppressive effects.
• Some of these medications treat cancer, but in much larger doses than those used for RA.

Adverse Drug Reactions

• Adverse reactions include dizziness, headache, blurred vision, and nausea/vomiting.
• These medications are hepatotoxic, and can cause liver damage.
• Bone marrow suppression can occur, decreasing platelets, red and white blood cells.
• Increased risk of infection due to immunosuppressive effects.
• Gastrointestinal ulceration and pulmonary fibrosis are additional adverse effects.
• Methotrexate and leflunomide are teratogenic and contraindicated during pregnancy.

Interventions

• Monitor lab values (RBC, WBC, and platelets) due to bone marrow suppression.
• Assess for manifestations of infection, regardless of normal red and white blood cell counts.
• Perform liver function tests and observe for jaundice to detect liver damage.
• Monitor clients on methotrexate for gastrointestinal bleeding.
• Watch for respiratory distress and decreased oxygenation, signs of pulmonary fibrosis.
• Monitor for abdominal pain and diarrhea, as well as nutritional status.

Administration

• Administer methotrexate once a week for RA.
• It can be given orally, subcutaneously, or IM.
• Auto-injectors are available for self-administration.
• Start at a low dose and increase it as needed.
• Folic acid supplements may be prescribed to reduce toxicity.

Client Instructions

• Maintain hydration (2 L per day) to aid kidney excretion of the medication.
• Report yellowing of the skin or eyes.
• Report manifestations of infection like fatigue, chills, and fever.
• Report ulcerations of the mucous membranes of the mouth and tongue.
• Report any abnormal bleeding, bruising, or petechiae.
• Report blood in vomitus or stools.
• Report difficulty breathing or shortness of breath.
• Use contraception due to teratogenic effects of methotrexate.
• Avoid breastfeeding while on methotrexate.
• Be aware of possible fertility issues and alcohol.

Contraindications and Precautions

• Use caution in clients with active bacterial or viral infections due to immunosuppression.
• Monitor closely for gastrointestinal bleeding and pain in clients with peptic ulcer disease or ulcerative colitis.
• Contraindicated in clients with liver insufficiency, hepatitis, or renal insufficiency, as well as alcohol use disorder and immunosuppression.
• Methotrexate and leflunomide are contraindicated for pregnant or breastfeeding clients.
• Sulfasalazine should be used with caution during lactation due to jaundice risk in infants.
• Hydroxychloroquine is considered safe for use during pregnancy.

Interactions

• Concurrent use of methotrexate and digoxin may reduce serum digoxin levels.
• Concurrent use of methotrexate with NSAIDs, salicylates, and/or sulfonamides may cause toxicity.
• Caffeine may reduce the effectiveness of methotrexate.
• Concurrent use of a nonbiologic DMARD with warfarin may increase bleeding risk.
• Alcohol ingestion with a nonbiologic DMARD may increase hepatotoxicity risk.

Review Questions

• Folic acid reduces toxicity from methotrexate.
• A sore throat is an adverse effect of methotrexate clients should watch for.

Explore nonbiologic csDMARDs, including methotrexate, leflunomide and others used to suppress the immune response in autoimmune disorders like RA. These medications slow RA progression but can cause adverse reactions such as dizziness, liver damage & bone marrow suppression.