Nursing 498 Winter 2025 Immunity PDF

IMMUNITY Nursing 498 Winter 2025 Catherine Fox Robyn Dhanoa Shelley de Boer 1  Objectives Identify safe, effective, nursing management of Select and prioritize nursing pharmacological ou...

IMMUNITY Nursing 498 Winter 2025 Catherine Fox Robyn Dhanoa Shelley de Boer 1  Objectives Identify safe, effective, nursing management of Select and prioritize nursing pharmacological outcomes and interventions interventions for individuals to develop a plan of care for across the lifespan and their individuals with chronic families dealing with chronic immune disorders. immune disorders. 2  For each drug classification, students must understand the following details based on Sealock & Seneviratne et al. (2021/2024) Generic Name/Trade Names Classification Indications Mechanism Of Action Ø pharmacokinetics – absorption, distribution, metabolism & excretion, half-life, Student onset/peak/duration) Contraindications/Precautions Preparation Adverse Reactions/Side Effects Ø toxicity and management of overdose Interactions (drug-drug, food-drug) Route/Dosage Nursing Considerations Ø Lab values/assessment and monitoring priorities Nursing interventions Patient and Family Teaching Additional ü Self Study: Human Immunodeficiency Virus (HIV) Before we begin, please remember students should complete an associated drug card for each drug classification. It's impossible to memorize all of the details they contain, but it's important to have them on hand at clinical for your reference so you can apply them to your patients. 3  Immune System: Defense Skin, mucous membranes, enzymes, natural 1st line of defense microbial flora Innate Immunity 2nd line of Phagocytes (granulocytes, macrophages) defense Adaptive 3rd line of Lymphocytes: T-cells, B-cells Immunity defense 4  T Cells: Central B Cells: Produce to immune antibodies and activation and contribute to cytokine autoimmune production. responses. Immune System: Key Players Antibodies: Bind Macrophages: to pathogens or Process antigens, self-antigens to secrete neutralize or flag cytokines, and them for initiate destruction. inflammation. 5  Cytokines: Immune Regulation What are Cytokines? Small proteins that act as messengers between immune cells. Key role in coordinating and regulating immune responses (inflammation, immune activation, and suppression). Type of Cytokine Function Examples Examples of Drug Classes Pro-inflammatory Drive inflammation and activate the immune TNF-alpha, IL-1, IL- TNF inhibitors (e.g., infliximab, Cytokines system 6 adalimumab); IL-6 inhibitors (e.g., tocilizumab) Anti-inflammatory Suppress inflammation and promote immune IL-10, TGF-beta Modulated indirectly by interferons (e.g., Cytokines regulation interferon-beta) Growth and Stimulate the growth, activation, and survival IL-2, IL-4, IL-7 JAK inhibitors (e.g., baricitinib, tofacitinib) Differentiation of T cells, B cells, and natural killer cells Cytokines Interferons Enhance antiviral defenses and modulate IFN-alpha, IFN- Interferons (e.g., interferon-beta for MS) immune activity beta, IFN-gamma Chemokines Guide immune cells to infection or injury sites CXCL8 (IL-8), CCL No direct drug classes, but important for immune cell migration Hematopoietic Stimulate the production and maturation of G-CSF, GM-CSF, Hematopoietic growth factors (e.g., Cytokines blood cells in the bone marrow EPO filgrastim, epoetin alfa)* 6  Tuberculosis Prior to beginning Hepatitis C and B any medication that Any acute (pneumonia) or chronic suppresses the infection (osteomyelitis) immune system, patients are Vaccination status typically screened Pregnancy status and potential for... considerations for future reproduction 7 Immune Modifying Therapy Nursing Implications Review of Agency Policies Regarding Administration of Immune Modifying Therapy It is essential to review the medication administration protocols of the University of Calgary and Alberta Health Services concerning who is permitted to administer immunosuppressants and the requirements for an independent double-check. Individual units may have their own specific safeguards. For example, at Foothills Medical Centre (FMC), Unit 37 does not allow nursing students to work with transplant patients. Safe Handling and Safe Disposal of Cytotoxic Medications 8 Immune Modifying Therapies Immunosuppressants: Drugs that reduce immune system activity (e.g., corticosteroids, calcineurin inhibitors). Immunomodulators: Drugs that regulate or enhance immune responses without broadly suppressing them (e.g., interferons, IVIG). 9 Immune Modifying Therapies Category Medication Class Broad Immunosuppressant Corticosteroids Targeted Immune Suppressants Calcineurin and mTOR inhibitors Cytotoxic and Antiproliferative Mycophenolate, JAK inhibitors Agents Antibody-Based Therapies Monoclonal and polyclonal antibodies Immune Modulators Interferons, interleukin inhibitors, IVIG *DMARDs Nonbiologic and biologic 10  Immune Modifying Therapy General Nursing Labs CBC & Differential Considerations C-reactive Protein (CRP) Head-to-Toe Assessment Considerations Allergy Liver Function Infection Hypertension Kidney Function Bleeding Toxicity: liver, kidney, or lung Chest radiograph (CXR) Side effects associated with inhibiting cell division As part of the “right assessment.” Serum drug levels ü Confirm the last dose time to prevent pharmacokinetic disruption ü Confirm the last dose time to prevent pharmacokinetic disruption ü Always safeguard against potential drug/drug and/or drug/food interactions. 11  Examples: Prednisone, Dexamethasone, Methylprednisolone. Indications: Short-term management of acute immune flares (e.g., lupus, RA). Adjunct in transplant rejection prevention. Used in combination with other immunosuppressives for long-term disease control. Corticosteroids: Corticosteroids like prednisone are frequently used as adjuncts to DMARD therapy during acute flares of Review rheumatoid arthritis or lupus Mechanism of Action: Reduce inflammation by inhibiting phospholipase A2, decreasing prostaglandin and leukotriene synthesis. Suppress immune response by reducing cytokine production and lymphocyte proliferation. Adverse Effects: Long-term use: Osteoporosis, hyperglycemia, hypertension, adrenal suppression, Cushing’s syndrome. Short-term use: Mood changes, fluid retention. Glucocorticoids cannot be abruptly stopped. 12  Examples: Cyclosporine, Tacrolimus Indications: Prevention of organ transplant rejection. Calcineurin Treatment of autoimmune diseases such as rheumatoid arthritis and psoriasis. Inhibitors Mechanism of Action: block calcineurin, a protein needed for activating T-cells and producing interleukin-2, which are essential for cellular proliferation; thereby suppressing the immune system 13  Adverse Effects: Nephrotoxicity Hypertension Hyperkalemia Neurological effects (e.g., tremors, Calcineurin headaches) Increased risk of infections Inhibitors Drug Interactions: Grapefruit juice (increases drug levels by inhibiting CYP3A4). NSAIDs (increased risk of kidney damage). Phenytoin, rifampin (reduce drug efficacy by increasing metabolism). 14  Examples: Sirolimus (Rapamune), Everolimus (Zortress) Indications: Organ transplant rejection prevention. Treatment of specific cancers (e.g., renal cell carcinoma). Mechanism of Action: mTOR inhibitors block mTOR, a protein that controls T-cell mTOR growth and division after being activated by interleukin-2. By interrupting this process Inhibitors these drugs suppress the immune system. Adverse Effects: Hyperlipidemia, thrombocytopenia, delayed wound healing Drug Interactions: CYP3A4 inhibitors (e.g., ketoconazole) increase drug levels. CYP3A4 inducers (e.g., rifampin) decrease efficacy. 15  Examples: Methotrexate, Azathioprine, Mycophenolate mofetil Indications: Lupus nephritis Autoimmune hepatitis Cytotoxic Rheumatoid Arthritis (Antiproliferative) Organ transplant maintenance therapy Agents Mechanism of Action: Antiproliferative drugs work by blocking DNA or RNA synthesis (through different pathways), preventing rapidly dividing immune cells like T and B lymphocytes from growing and functioning. This suppresses the immune system, making these drugs effective for treating autoimmune diseases and preventing transplant rejection. 16  Adverse Effects: Bone marrow suppression (anemia, leukopenia, thrombocytopenia) GI disturbances (nausea, vomiting, diarrhea) Cytotoxic Hepatotoxicity (Antiproliferative) Increased infection risk Agents Drug Interactions: Allopurinol (increases azathioprine toxicity). Antacids and cholestyramine (reduce absorption of mycophenolate). 17  Examples: Tofacitinib, Baricitinib Indications: Rheumatoid arthritis, Psoriatic arthritis, Ulcerative colitis Mechanism of Action: block Janus kinase (JAK) Cytotoxic pathways, which are crucial for transmitting signals from cytokines that activate the (Antiproliferative) immune system. By disrupting this signaling, Agents: they reduce inflammation and immune overactivity, making them effective for Janus Kinase (JAK) autoimmune diseases. Inhibitors Adverse Effects: Increased risk of infections, elevated liver enzymes, thrombosis Drug Interactions: CYP3A4 inhibitors/inducers can alter drug metabolism. 18  Examples: Infliximab (Remicade), Rituximab (Rituxan), Adalimumab (Humira) Indications: Rheumatoid arthritis Crohn’s disease and ulcerative colitis Psoriatic arthritis Multiple sclerosis Monoclonal Mechanism of Action: Antibodies Infliximab/Adalimumab: TNF-alpha inhibitors block tumour necrosis factor- alpha (TNF-alpha), a key inflammatory cytokine, to reduce inflammation and immune system overactivity. Rituximab: Targets CD20, a protein on B lymphocytes, marking them for destruction. This reduces B cell-driven immune responses 19  Adverse Effects: Infusion-related reactions (fever, chills, rash) Increased risk of infections Monoclonal Drug Interactions: Live vaccines (contraindicated during Antibodies therapy). Concurrent immunosuppressive drugs (increases risk of severe infections). 20  Example: Anti-Thymocyte Globulin (ATG) (Thymoglobulin, Atgam) Indications: Prevention and treatment of acute organ transplant rejection. Aplastic anemia unresponsive to other therapies. Mechanism of Action: made from animals (rabbits or horses) immunized with human T cells, these antibodies target multiple T-cell antigens. They bind to T cells, leading to their destruction by the immune system. This suppresses the immune response and is used to treat Polyclonal transplant rejection or severe autoimmune diseases Adverse Effects: Antibodies Infusion reactions (e.g., fever, chills, hypotension) Risk of infection due to immunosuppression Serum sickness (delayed hypersensitivity reaction). Drug Interactions: Immunosuppressants (e.g., calcineurin inhibitors): Additive immunosuppressive effects increase infection risk. Live vaccines: Contraindicated during therapy due to immunosuppression. BC Transplant: Medication Guidelines 21  Examples: Interferon beta-1a (Avonex, Rebif), Interferon beta-1b (Betaseron). Indications: Multiple Sclerosis (MS): Reduces relapse rates in relapsing-remitting MS. Mechanism of Action: : Interferon beta reduces inflammation by altering cytokine production. It decreases the levels of pro-inflammatory cytokines while increasing the levels of anti-inflammatory cytokines. This shift calms the overactive immune system, which helps Interferons reduce the damage to myelin in Multiple Sclerosis (MS). By controlling inflammation, interferons play a role in slowing the progression of MS and reducing the frequency of relapses. Adverse Effects: Flu-like symptoms, injection site reactions, depression. Drug Interactions: Immunosuppressants: Increased risk of infections. Hepatotoxic drugs: Additive liver toxicity. Treatments for MS 22  Examples: Tocilizumab (Actemra), Secukinumab (Cosentyx), Ustekinumab (Stelara). Indications: Rheumatoid arthritis (Tocilizumab). Psoriatic arthritis, ankylosing spondylitis (Secukinumab). Crohn’s disease, psoriasis (Ustekinumab). Mechanism of Action: Blocks specific interleukin pathways to reduce inflammation and immune activation. Interleukin Adverse Effects: Inhibitors Increased infection risk. Injection site reactions. Drug Interactions: Avoid live vaccines during therapy. Immunosuppressants: Additive effects increase infection risk. Canadian Association for Psoriasis Patients: Treatment Arthritis Society Canada: Tocilizumab Crohn’s and Colitis of Canada: Biologics 23  Examples: Gammagard, Privigen. Indications: Immune thrombocytopenia (ITP). Kawasaki disease. Primary immunodeficiencies. Mechanism of Action: Intravenous Provides passive immunity. Immunoglobulin Modulates immune responses by neutralizing (IVIG): Review autoantibodies and inflammatory cytokines. Adverse Effects: Infusion reactions, headache, thromboembolism. Drug Interactions: Avoid live vaccines within 6 months of IVIG therapy. Canadian Blood Services: Immunoglobulin Products 24  Medications that slow or halt the progression of autoimmune diseases, particularly rheumatic disorders. Indication: Reduce inflammation, prevent joint damage, and improve long-term outcomes. Disease Categories: Modifying Non-Biologic DMARDs: Synthetic compounds that broadly suppress the immune system. Antirheumatic Examples: Methotrexate, Sulfasalazine, Leflunomide, Hydroxychloroquine. Drugs Biologic DMARDs: Targeted therapies that interfere (DMARDs) with specific immune pathways. Examples: infliximab, adalimumab Many DMARDs are used beyond rheumatic diseases (e.g., IBD, psoriasis, and transplant rejection). Arthritis Society Canada: Medication Reference Guide: NonBiologic Arthritis Society Canada: Medication Reference Guide: Biologic 25  Methotrexate: Inhibits dihydrofolate reductase, reducing DNA synthesis and T-cell activation. Indications: Rheumatoid arthritis, psoriasis, and some cancers. Adverse Effects: Bone marrow suppression, hepatotoxicity, stomatitis. Drug Interactions: NSAIDs, TMP-SMX, PPIs, Aspirin/Salicylates, Folic Acid/Folinic Acid, Nonbiologic Penicillins, Alcohol, Leflunomide, Live Vaccines DMARDs Sulfasalazine: Reduces inflammation by modulating immune pathways. Indications: Rheumatoid arthritis, ulcerative colitis. Adverse Effects: GI disturbances, hypersensitivity reactions. Drug Interactions: Folic Acid, Methotrexate, Antibiotics, Warfarin 26  Hydroxychloroquine: interferes with how macrophages process antigens, reducing their ability to activate T cells. Indications: Rheumatoid arthritis, lupus. Adverse Effects: Retinopathy (requires regular eye exams). Drug Interactions: Tamoxifen, Digoxin, Antacids Nonbiologic Leflunomide (Arava): blocks pyrimidine synthesis, which is essential for DNA DMARDs production in rapidly dividing cells like lymphocytes. This slows lymphocyte proliferation, reducing immune system activity. Indications: Rheumatoid arthritis. Adverse Effects: Hepatotoxicity, hypertension, gastrointestinal disturbances. Drug Interactions: Warfarin (increased bleeding risk); other hepatotoxic drugs. 27  Infliximab (Remicade) Indications: Rheumatoid arthritis, Crohn’s disease, psoriasis. Adverse Effects: Infusion reactions, infections (e.g., TB). Adalimumab (Humira) Indications: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, IBD. Adverse Effects: Infections, injection site reactions, increased risk of malignancies. Biologic Rituximab (Rituxan) DMARDs Target: CD20 on B lymphocytes. Indications: Rheumatoid arthritis (refractory), lupus, certain cancers. Adverse Effects: Infusion reactions, hepatitis B reactivation, hypogammaglobulinemia. Etanercept (Enbrel) Indications: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis. Adverse Effects: Injection site reactions, increased risk of infections. 28 Chronic Immune Disorders 29  Chronic autoimmune disorder causing inflammation of synovial joints. Affects multiple systems if untreated, leading to joint deformity and disability. DMARDs (non-biologic and biologic) are foundational treatments; nursing management is critical for monitoring side effects and maintaining function. Treatment Self management: low intensity, low impact exercise to combat joint stiffness, healthy diet, physiotherapy and occupational therapy Rheumatoid Medication Management Non-Biologic DMARDs: Arthritis (RA) Most common: Methotrexate (cornerstone therapy) with folic acid Sometimes: Sulfasalazine, Hydroxychloroquine, Leflunomide; Often used in combination. Biologic DMARDs: TNF-alpha inhibitors (e.g., infliximab, adalimumab). IL-6 inhibitors (e.g., tocilizumab) for refractory cases. Corticosteroids: Short-term use for acute flares. NSAIDs: Used in patients to promote physical comfort. Monitor patients for GI and renal effects 30  Interprofessional Collaboration, Nursing Management and Patient Teaching Physiotherapy helps maintain joint motion and muscle strength Occupational therapy helps to develop upper extremity function and encourages joint protection through the use of splints or other devices Suggest strategies for activity pacing Rheumatoid A caring, long-term relationship with RA healthcare team and/or support group can promote a patient’s self-esteem Arthritis (RA) and positive coping. Encourage patients considering complementary therapies like massage therapy, naturopathic medicine, special herbs, supplements, acupuncture, and meditation to discuss these with their MRHP. A dietitian can provide personalized education based on the patient's context, such as the risk of osteoporosis from corticosteroid therapy or changes in appetite that may lead to weight gain or loss, or underlying disease processes. 31  Nursing Management and Patient Teaching Collaborate with the team and the patient to develop an action plan and coping strategies to manage: Fatigue Rheumatoid Pain Arthritis (RA) Depression Limited endurance and mobility deficits Prevent exacerbations Age-related considerations 32  Drug Therapy for JIA: NSAIDS are first line agents: ibuprofen, naproxen Non-Biologic DMARDs: methotrexate Corticosteroids Biologic DMARDs: effective in this population, with ongoing studies regarding long-term use Juvenile Physiotherapy is individualized for each patient and Idiopathic specific to each joint, strengthen muscles, mobilize restricted joint motion, and prevent or correct deformities Arthritis Occupational therapy assumes the role for generalized mobility and ADL Relieve pain Pharmacologically (opioids are only short-term) and non-pharmacological modalities 33  Multisystem autoimmune disorder characterized by periods of flares and remission. Common symptoms: fatigue, joint pain, skin rashes (e.g., butterfly rash), kidney involvement (lupus nephritis). First-Line Therapy: Nonbiologic DMARDs: Hydroxychloroquine Systemic Lupus Reduces disease flares. Adjuvant Therapies Erythematosus Corticosteroids: For acute flares and organ- (SLE) threatening disease. NSAIDs: Used in patients with mild polyarthralgia or polyarthritis. Monitor patients for GI and renal effects. Cytotoxic Agents: methotrexate, azathioprine, Mycophenolate mofetil, cyclophosphamide. Biologic DMARDs: Belimumab for refractory cases. 34  Nursing Management and Patient Teaching: Educate patients on sun protection to prevent flares. Monitor for signs of kidney involvement (e.g., proteinuria, edema). Teach infection prevention strategies due to Systemic Lupus immunosuppressive therapy. Erythematosus Address psychosocial support needs (e.g., (SLE) fatigue management, mental health resources). Patients on Hydroxychloroquine can experience retinal toxicity -> retinopathy. All patients must have complete baseline ophthalmologic exams and regular follow - up exams annually (or as directed by MRHP) 35  Lifelong immunosuppressive therapy required to prevent graft rejection. Common organs: kidney, liver, heart, lung. Calcineurin Inhibitors: Tacrolimus, Cyclosporine (cornerstones for rejection prevention). Transplant mTOR Inhibitors: Sirolimus, Everolimus for adjunct therapy. Corticosteroids: Prednisone for early post- transplantation and flare management. Polyclonal Antibodies: Anti-thymocyte globulin for acute rejection. BC Transplant: Medication Guidelines 36  Nursing Management Monitor for rejection symptoms: fever, graft dysfunction (e.g., creatinine elevation in kidney transplant). Assess for medication side effects: Nephrotoxicity with calcineurin inhibitors. Transplant Hyperlipidemia with mTOR inhibitors. Therapeutic level monitoring for calcineurin and mTOR inhibitors. Provide infection prevention education: hand hygiene and avoiding crowds. Coordinate care with the multidisciplinary team (e.g., dietitian, pharmacist). 37 Immune Deficiency 38  SCID is a rare, life-threatening condition characterized by severe defects in both T-cell and B-cell function, leading to profound immune deficiency. Treatment for SCID is HSCT from a histocompatible donor, a haploidentical donor (usually a parent), or a matched unrelated donor. IVIG infusions and Pneumocycstitis jiroveci pneumonia Severe Combined (PJP) prophylaxis are used to augment the humoral Immunodeficiency immunity until the transplant is performed. (SCID) Nursing care focuses on preventing infection and supporting the child and family Prognosis for SCID is very poor if a compatible bone marrow donor is not available, nursing care is directed at supporting the family in caring for a child with a life- threatening illness Genetic counselling is essential because of the modes of transmission in either form of the disorder 39  Resources Lupus Society of Alberta - https://lupus.ab.ca/ Lupus Canada- https://www.lupuscanada.org/ Lupus Foundation of America- https://www.lupus.org/ Alberta Rheumatology - https://albertarheumatology.com/ Rheumatoid Arthritis Society of Canada- https://arthritis.ca/about- arthritis/arthritis-types-(a-z)/types/rheumatoid-arthritis 40