Pharmacology of Immunosuppressants and Monoclonal Antibodies

Pharmacology and Nursing Interventions for Patients with Chronic Alterations in Immunity

• The presentation covers various chronic immune disorders, their pharmacological interventions, nursing considerations, and treatment.
• Topics include immunosuppressant medications, biological response-modifying drugs and antirheumatic medications, cannabis and HIV, Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis, and Severe Combined Immunodeficiency (SCID)

Immunosuppressant Therapy

• Mechanism of Action: Drugs decrease or prevent immune responses.
• Classes: Azathioprine, cyclosporin, sirolimus, tacrolimus, and corticosteroids.
• Corticosteroids (Glucocorticoids) used for SLE and RA.
• Contraindications: Known drug allergy, kidney/liver failure, uncontrolled infection, concurrent radiation therapy.
• Important Note: Not contraindicated during pregnancy, but use cautiously.

Anti-Rejection Medications

• Azathioprine: Blocks purine metabolism, inhibiting T-cell responses.
• Cyclosporin: Inhibits T-cell synthesis, blocking cytokine production.
• Tacrolimus: Inhibits T-cell synthesis.

Adverse Events of Immunosuppressant Anti-rejection Medications

• Azathioprine (Imuran): Leukopenia, thrombocytopenia, hepatotoxicity.
• Cyclosporine (Ciclosporin): Moderate HTN, neurotoxicity, hepatotoxicity, nephrotoxicity, post-transplant diabetes mellitus.
• Tacrolimus: Agitation, anxiety, confusion, hallucinations, neuropathy, albuminuria and other renal issues.

Immunosuppressant Therapy: Drug Interactions

• Inhibits metabolism: Fluconazole, ketoconazole, clarithromycin, protease inhibitors, grapefruit juice (with cyclosporin).
• Induces metabolism: Phenytoin, carbamazepine, St. John's Wort, rifampin.

Corticosteroids

• Mechanism of Action: Inhibit inflammation by stabilizing cell membranes.
• Drug Names: Prednisone, methylprednisolone sodium succinate, prednisolone sodium phosphate, triamcinolone acetonide.
• Indications: Allergies, autoimmune diseases, organ transplantations.
• Adverse Effect: Cushing syndrome.

Cushing Syndrome

• Systemic effect of corticosteroid use.
• Symptoms: Moon face, truncal obesity, "buffalo hump," wasting of muscle mass, increased blood glucose, increased sodium levels, and loss of potassium.

Biological Response-Modifying Drugs and Antirheumatic Medications

• Purpose: To alter the body's response to autoimmune, inflammatory, and infectious diseases.
• Types: Immunomodulating drugs - interferons, monoclonal antibodies— and Disease-modifying antirheumatic drugs (DMARDs).

Immunomodulating Drugs: Interferons

• Mechanism of Action: Restore immune system function if impaired, augment its ability to function as the body's defense, and inhibit it from working as in autoimmune dysfunction
• Contraindications: Known drug allergy, hepatitis, or liver failure, concurrent use of immunosuppressants, AIDS-related Karposi sarcoma, severe depression, and severe liver disease.
• Adverse Effects: Flu-like symptoms (fever, chills), cardiovascular effects (tachycardia, cyanosis, ECG changes, orthostatic hypotension), central nervous system effects (confusion, somnolence, irritability, seizures, hallucinations), gastrointestinal effects (nausea, diarrhea, vomiting, anorexia), hematological effects (neutropenia, thrombocytopenia), and renal/hepatic effects (increased BUN/creatinine levels, proteinuria, abnormal liver function tests).

Immunomodulating Drugs: Monoclonal Antibodies

• Mechanism of Action: Prevents TNF-alpha from binding to TNF cell surface receptors; modulates inflammatory responses.
• Specific Drugs and Indications: Adalimumab for RA, Psoriatic arthritis, AS, Crohn's disease, psoriasis; Infliximab for AS, Crohn's disease, RA, and ulcerative colitis—psoriatic arthritis.
• Adverse Effects: Severe allergic inflammatory-type infusion reactions.

Immunomodulating Drugs: Interleukins

• Mechanism of action: Inhibits the binding of IL-1 or IL-6 to its corresponding receptor. Specifically mentioned Anakinra (IL-1 receptor antagonist), and tocilizumab(IL-6 antagonist).
• Adverse Effects: Infection, injection site reaction, headache.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

• Purpose: Alter underlying disease rather than treating symptoms.

• Action: Exhibit anti-inflammatory, antiarthritic, and immunomodulating effects; inhibit cell movement into inflamed areas.

• Non-Biologic DMARDs: Methotrexate, Leflunomide, Hydroxychloroquine sulphate, Sodium aurothiomalate, Cyclosporine, Azathioprine, Sulfasalazine.

• Biologic DMARDs: Adalimumab, Certolizumab, Abatacept, Golimumab, Rituximab, Infliximab, Tocilizumab, Adalimumab, Tofacitinib, Anakinra, Etanercept.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Mechanism of Action, Contraindications, and Nursing Considerations

• Mechanism of Action: Varies with each medication.
• Contraindications: Active bacterial infections, active herpes, active or latent TB, and acute or chronic hepatitis B or C.
• Nursing Considerations: Main adverse event is bone marrow suppression; monitor RBC, WBC, platelets, and LFTs.

Cannabis

• Mechanism of Action: Affects the endocannabinoid system, influencing homeostasis and physiological processes.
• Short-Term Studies: Support use for HIV/AIDS weight loss, MS pain, and chronic pain including rheumatologic conditions.
• How it Works: The ECS is composed of CB1 and CB2 receptors, plus endogenous cannabinoids (like anandamide). Cannabinoids modulate various bodily functions, like appetite, digestion, and, pain.
• Risks: Mental health conditions; impaired driving; respiratory issues; addiction, and dependence, psychological issues. Various side Effects such as psychological symptoms, nausea, weight loss can also appear.
• Contraindications: Patients under 25 years with rheumatic conditions; patients with allergic reactions to cannabinoids; pregnant and breastfeeding women. patients with psychosis; or substance abuse disorder.

Nursing Management for Patients Living with Systemic Lupus Erythematosus (SLE)

• Drug Therapy: NSAIDs (mild polyarthritis), DMARDs (hydroxychloroquine), Corticosteroids (Methylprednisolone)
• Monitor for: GI and renal effects, specific ophthalmologic exams with hydroxychloroquine (retinopathy), and long term use of corticosteroids.
• Nursing Diagnoses: Fatigue (chronic inflammation and immune changes), and impaired comfort (variable and unpredictable disease progression)
• Patient Teaching: Avoid harsh chemicals and soaps; limit environmental triggers for infections; emotional and physical stress management, maintain balance of lifestyle. Monitor skin for rashes, joint pain; and other conditions. Manage pain, fatigue, lupus fog, and other issues.

Nursing Management for Patients Living with Rheumatoid Arthritis (RA)

• Drug Therapy: NSAIDs (GI and renal monitoring), DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide), immunosuppressants (tofacitinib), biologics (etanercept, infliximab, adalimumab), corticosteroids (prednisone); monitor effectiveness and side effects.
• Nursing Diagnoses: Impaired physical mobility because of joint damage, pain, stiffness, and chronic pain.
• Patient Teaching: Activity pacing, joint protection, complementary therapies(massage, herbs, supplements, acupuncture, and meditation). Importance of diet, managing fatigue, and emotional health. Discuss pain management and disease process. Understand age related considerations from the patient perspective.

Helping Children Live Well with Rheumatoid Arthritis

• Drug Therapy for Juvenile Idiopathic Arthritis (JIA): NSAIDs (first-line), DMARDs (methotrexate), and corticosteroids, biologics.
• Therapies: Physiotherapy and occupational therapy to maximize mobility, joint protection, and activities of daily living (ADL).

Nursing Considerations for Children with Rheumatoid Arthritis

• Importance of promoting: General health through well-balanced diet, sleep and rest, and caloric intake; physical and emotional support for the child and family.
• Other Considerations: School attendance, family support, summer camps.

Severe Combined Immunodeficiency (SCID)

• Therapeutic Management: Hematopoietic stem cell transplant (HSCT) from a histocompatible donor; and augment humoral immunity with IVIg and prophylaxis prior.
• Nursing Considerations: Prevent infections; support family and child (life-threatening disease); genetic counseling.

Healthcare Professional Resources

• Various websites are provided as resources for SLE, Lupus, Arthritis, etc..