NURS 498 W1 Student Slides-Immunity 2 - Pharmacology & Nursing Interventions

Pharmacology and Nursing Interventions for Patients with Alterations in Chronic Immunity Cydnee Seneviratne Shelley De Boer Catherine Fox/Kaleigh McCartney/Twyla Ens N498 Winter...

Pharmacology and Nursing Interventions for Patients with Alterations in Chronic Immunity Cydnee Seneviratne Shelley De Boer Catherine Fox/Kaleigh McCartney/Twyla Ens N498 Winter 2025  Topics for this Lecture: Immunosuppressant Systemic Lupus Medications Erythrematosus (SLE) Biological Response Rheumatoid Arthritis (RA) Modifying Drugs and  Juvenile Idiopathic Antirheumatic Drugs Arthritis Cannabis Severe Combined Human Immunodeficiency Immunodeficiency (SCID) Virus (HIV)   Critically reflect upon the pharmacological interventions and nursing considerations/interventions By the End of for patients living with chronic immune disorders: this Lecture,  Systemic Lupus Erythematosus (SLE) You Will:  Rheumatoid Arthritis and Juvenile Idiopathic Arthritis  Severe Combined Immunodeficiency (SCID)  Autoimmune Treatment and Interventions  Immunosuppressant Therapy  Mechanism of Action: Drugs that decrease or prevent an immune response.  Classes:  Anti-rejection medications such as azathioprine sodium, cyclosporin, sirolimus, and tacrolimus  Corticosteroids (Glucocorticoids)** (indications for SLE and RA)  Contraindications:  Known drug allergy  Assess for kidney or liver failure, HTN, uncontrolled infection, and concurrent radiation therapy  Not contraindicated during pregnancy but must be used cautiously  Anti-Rejection Medications Drug Names Mechanism of Action Indication Azathioprine sodium (Imuran®) Blocks metabolism of purines, inhibiting the Prevention of organ rejection in kidney synthesis of T cell DNA, RNA, and proteins, transplantation; treatment of rheumatoid thereby blocking immune response arthritis Cyclosporin (Sandimmune®, Neoral®, Inhibits synthesis of T cells by blocking the Prevention of graft rejection following solid Cyclosporin®) production and release of the cytokine organ and bone marrow transplantation; mediator IL-2 treatment of rheumatoid arthritis and psoriasis Tacrolimus (Advagraf®, Prograf®) Inhibits T cell synthesis, possibly by binding Prevention of organ rejection in liver, to an intracellular protein known as FK- kidney, and heart transplantation; binding protein 12 unlabelled uses† include rejection in bone marrow, pancreas, pancreatic islet cell, and small intestine transplantation, as well as treatment of autoimmune diseases and severe psoriasis Immunosuppressant Therapy: Anti-rejection Medications  Adverse Events: Drug Body System Adverse Effects Azathioprine sodium Hematological Leukopenia, thrombocytopenia (Imuran) Hepatic Hepatotoxicity Cyclosporine Cardiovascular Moderate HTN (Ciclosporin) CNS Neurotoxicity including tremors Hepatic Hepatotoxicity with cholestasis and Renal hyperbilirubinemia Other Nephrotoxicity Post-transplant diabetes mellitus, gingival hyperplasia, and hirsutism Tacrolimus CNS Agitation, anxiety, confusion, hallucinations, Renal neuropathy Other Albuminuria, dysuria, AKI, kidney tubular necrosis Post-transplant diabetes mellitus  Immunosuppressant Therapy: Drug Interactions of Cyclosporine, Sirolimus, and Tacrolimus Induces metabolism Inhibits metabolism of medication and and reduces effect of increases circulating drug levels  Fluconazole and  Phenytoin ketoconazole  Carbamazepine  Clarithromycin  St. John’s Wort  Protease Inhibitors (HIV/Hep  Rifampin C antiviral drugs)  Grapefruit juice (inhibits absorption as well if given with cyclosporin)  Corticosteroids Drug Names Mechanism of Action Indication Prednisone Inhibit or help control the Allergies, autoimmune (methylprednisolone sodium inflammatory response by diseases, and organ succinate, prednisolone stabilizing the cell transplantations. sodium phosphate, and membranes of inflammatory triamcinolone acetonide) cells Cushing Syndrome  A systemic effect of corticosteroid use.  Following signs and symptoms:  Moon face  Truncal obesity  “Buffalo hump”  Wasting of muscle mass  Increased blood glucose  Increased sodium levels  Loss of potassium   Purpose:  To alter the body’s response to diseases such as autoimmune, inflammatory, and infectious Biological diseases Response-  Enhance or restrict the patient’s immune response to disease and can stimulate a patient’s Modifying hematopoietic function, and can prevent disease Drugs and  Two broad classes: Antirheumati  Immunomodulating drugs (biologics) interferons, monoclonal c Medications antibodies, interleukin receptor agonists and antagonists  Disease modifying antirheumatic drugs (DMARDs) Immunomodulating Drugs: Interferons  Interferons (IFNs): are proteins that have three basic properties: antiviral, anti tumor, and immunomodulation. Chemically they are glycoproteins.  Mechanism of Action:  Restore immune system function if impaired  Augment its ability to function as the body’s defense  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  Immunomodulating Drugs: Interferons  Adverse Effects:  Flu-like-symptoms such as fever, chills, headache, Body System malaise, myalgia, Adverse and fatigue Effects General Flu like syndrome, fatigue* CVS Tachycardia, cyanosis, ECG changes, orthostatic hypotension CNS Confusion, somnolence, irritability, seizures, hallucinations GI Nausea, diarrhea, vomiting, anorexia, taste alterations, dry mouth Hematological Neutropenia, thrombocytopenia Renal/ Hepatic Increased BUN and creatinine levels, proteinuria, abnormal Liver function tests   Indications: Used for treatment of cancer, rheumatoid arthritis, other inflammatory disorders, Multiple Sclerosis and organ transplantation  Mechanism of Action: Immunomodulati  Anti-TNF-alpha- prevents TNF-alpha molecules from binding to TNF cell-surface receptors as part of the RA disease process. Also modulates the inflammatory biologic ng Drugs: responses that are induced or regulated by TNF. Monoclonal  Adalimumab (Humira) –moderate to sever RA, Psoriatic arthritis, AS, Crohn’s disease, Antibodies-”mab’  psoriasis Infliximab (Remicade)- AS, Crohn’s s” disease, RA, ulcerative colitis, psoriatic arthritis  Adverse Effects:  Severe allergic inflammatory-type infusion reactions occur in varying percentages of patients, therefore premedication with acetaminophen and/or diphenhydramine may be required   Interleukins: Classified as lymphokines, which are soluble proteins released from activated lymphocytes such as NK cells.  Mechanism of Action: Inhibits the binding of IL to its corresponding Immunomodulati receptor sites: ng Drugs:  Anakinra(Kineret)- IL-1 receptor antagonist Interleukins  Tocilizumab(Actemra)- IL-6 receptor antagonist (not included in text)  Adverse Effects: Infection, injection site reaction, headaches. Monitor blood work closely Disease-Modifying Anti-Rheumatic Drugs (DMARDs)  Purpose:  Act by altering the underlying disease rather than treating symptoms § Exhibit anti-inflammatory, antiarthritic, and immunomodulating effects  Inhibit movement of various cells into an inflamed, damaged area, such as a joint  Disease-Modifying Anti-Rheumatic Drugs  Two categories: (DMARDs) Non-Biologic Biologic Methotrexate* Adalimumab* Leflunomide* Certolizumab* Abatacept* Hydroxychloroquine §Golimumab* Rituximab sulphate* Tocilizumab §Infliximab* Sodium aurothiomalate Cyclosporine §Adalimumab* Tofacitinib Azathioprine §Anakinra* Sulfasalazine Etanercept*  Disease-Modifying Anti-Rheumatic Drugs (DMARDs)  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  Varying contraindications depending on the drug  Nursing Considerations:  Main adverse event is bone marrow suppression  Must monitor at baseline and throughout, RBC, WBC, and platelets, LFT  Cannabis  There are short-term studies that support the use of smoked or vaporized cannabis for HIV/AIDS associated-weight loss, multiple sclerosis-related pain and spasticity, neuropathic pain and chronic pain of various etiologies such as in the case of rheumatoid arthritis and pain associated in lupus  How does it work?  The endocannabinoid system is designed for homeostasis and regulation: Sleep Reproduction and Immune function fertility Appetite Pleasure and reward Digestion Memory Mood Temperature regulation Motor control Pain   Precipitation of psychotic symptoms  Impaired pulmonary function from inhalation  Impaired cognition and potential interactions with psychoactive Risks drugs Associated  Dependence  Infertility with the Use  Neurodevelopmental disorders following in utero exposure of Cannabis  Impaired driving while under the influence of marihuana  Impact on insurance and benefits coverage  Unauthorized diversion Contraindications for Cannabis 1. Cannabis should not be used in the following patient populations: a.Rheumatology patients under the age of 25 years b.Patients with allergic reactions to cannabinoid products c.Women who are pregnant or breastfeeding d.Patients with a history of current or past psychotic illness, substance abuse disorder, previous suicide attempts or suicidal ideation 2. Cannabis should be used with caution in the following patient populations: a.Elderly patients b.Patients with unstable mental health disease c.Patients with a history of current moderate or severe cardiovascular or pulmonary disease d.Patients working in settings requiring high levels of concentration, optimal executive functioning and alertness e.Patients receiving concomitant therapy with sedative-hypnotics or other psychoactive drugs Nursing Management for Patients Living with Systemic Lupus Erythematosus (SLE) Systemic Lupus Erythematosus (SLE): Drug Therapy  NSAIDs  Used in patients with mild polyarthralgia or polyarthritis  Monitor patients for GI and renal effects  DMARDs hydroxychloroquine and chloroquine  Treat fatigue and moderate skin and joint problems and SLE flares  Outcomes from therapy not noticed for months  Hydroxychloroquine monitor eyes and get regular eyes exams every 6-12 months d/t retinopathy  Corticosteroids IV Methylprednisolone  Must taper steroid medications  Used in preventing exacerbations of polyarthritis  Immunosuppressant therapy Methotrexate, azathioprine (Imuran), cyclophosphamide  Reduce use of long-term corticosteroid therapy Nursing Diagnoses for Patients living with Systemic Lupus Erythematosus (SLE)  Fatigue related to physical deconditioning (chronic inflammation and altered immunity)  Impaired comfort related to insufficient situational control (symptoms of illness, treatment adverse effects, variable and unpredictable disease progression)  Systemic Lupus Erythematosus (SLE): Patient Teaching  The following instructions should be included in the teaching plan for a patient with systemic lupus erythematosus and the caregiver.  Avoidance of drying soaps, powders, household chemicals  Avoidance of exposure to individuals with infection  Avoidance of physical and emotional stress  Community resources and health care agencies  Disease process  Energy conservation and pacing techniques  Systemic Lupus Erythematosus (SLE): Patient Teaching  Marital and pregnancy counselling as needed  Names of drugs, actions, adverse effects, dosage, administration  Pain management strategies  Regular medical and laboratory follow-up  Therapeutic exercise, use of heat therapy (for arthralgia)  Use of sunscreen protection (at least SPF 15), with minimal sun exposure between the hours of 1100 and 1500  Systemic Lupus Erythematosus (SLE): Patient Teaching  Made adjustments as a family  Take time for yourself  Managing work with lupus  Managing school with lupus  Eating healthy and encourage physical activity  Manage fatigue  Manage lupus fog  Manage pain  Protect yourself for infections Nursing Management for Patients Living with Rheumatoid Arthritis (RA)   NSAIDs  Used in patients to promote physical comfort  Monitor patients for GI and renal effects  DMARDs methotrexate and sulphasalazine and hydroxychloroquine  Methotrexate reduces clinical symptoms for days to weeks  Rheumatoid Outcomes from therapy not noticed for months  Sulfasalazine and Hydroxychloroquine are effective for mild to moderate disease Arthritis:  Leflunomide blocks immune cell over production teratogenic Drug Therapy  Tofacitinib is used for mod to severe RA inhibits the enzyme janus kinase that causes joint inflammation  Immunomodulators tumour necrosis factor inhibitors such as etanercept, infliximab, adalimumab  Corticosteroids low dose prednisone  Interleukins Anakinra  Used in combination with DMARDs but not with immunomodulators Nursing Diagnoses for Patients living with Rheumatoid Arthritis  Impaired physical mobility related to pain (joint pain, stiffness, and deformity)  Chronic pain related to injury agent (joint inflammation, overuse of joints, and ineffective pain or comfort measures)  Disturbed body image related to altered self-perception (chronic disease activity, long term treatment, deformities, stiffness, and inability to perform usual activities) Rheumatoid Arthritis(RA): Patient Teaching  Physiotherapy helps maintain joint motion and muscle strength  Occupational therapy helps to develop upper extremity function and encourages joint protection through the se of splints or other devise  Suggest strategies for activity pacing  Caring, long-term relationship with an arthritis health care team can promote patient’s self-esteem and positive coping  Suggest complementary therapy such as massage therapy, naturopathic medicine, special herbs, supplements, acupuncture and meditation  Balanced nutrition monitor weight gain due to corticosteroid therapy and increased food intake or immobility and possible weight loss due to loss of appetite   Manage fatigue  Manage pain  Manage depression Rheumatoid  Coping strategies related to limited endurance and mobility deficits Arthritis(RA):  Be aware of surgical therapy may be necessary to relieve pain and Patient improve function Teaching  Manage care of joints  Make time for rest  Age-related considerations Helping Children Live Well with Rheumatoid Arthritis  Drug Therapy for JIA:  NSAIDS are first line agents ibuprofen, naproxen  DMARDs methotrexate  Corticosteroids  Biological agents immunomodulators  Physiotherapy is individualized for each patient and specific to each joint, strengthen muscles, mobilize restricted joint motion, and prevent or correct deformities  Occupational therapy assumes the role for generalized mobility and ADL  Relieve pain  Pharmacologically (opioids are only short-term) and non-pharmacological modalities Nursing Considerations for Children with Rheumatoid Arthritis  Promote general health  Well-balanced diet is essential for growth  Caloric intake must match energy needs  Sleep and rest are essential as well  Electric bed, firm mattress, night time splints may be necessary. Teaching is needed on how to use the splint appropriately  Encourage attendance at school and maintain social structures  Adherence  Encourage heat and exercise  Support the child and family  Family days  Summer camps for children with arthritis (Camp Kindle)  Healthcare Professional 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)/t ypes/rheumatoid-arthritis  Medical Cannabis- Arthritis Society- https://arthritis.ca/treatment/medication/medical-cann abis  Severe Combined Immunodeficien cy (SCID) Nursing Considerations for a Child Living with Severe Combined Immunodeficiency Therapeutic Management  Treatment for SCID is hematopoetic stem cell transplant (HSCT) from a histocompatible donor.  Augment the humoral immunity (e.g., IVIG, PJP prophylaxis) until the transplant is performed. Nursing Care  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 Thank you