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Chapter 48: Immunosuppressant Drugs
Terms in this set (44)
What is the mechanism of action of the immunosuppressant drugs?
A. B Cells
-Rationale: All immunosuppressants have similar mechanisms of action in that they selectively suppress certain T-lymphocyte cell lines.
By suppressing the T-lymphocytes cell lines, they prevent their involvement in the immune response.
Which of the following drug(s) are used to prevent rejection of transplanted kidneys?
A. azathiprine (Imuran)
B. basiliximab (Simulect)
C. daclizumab (Zenapax)
D. Both B & C
E. None of the above
-Rationale: Simulect and Zenapax are drugs used to prevent rejection of transplanted kidneys.
These drugs are generally used as part of a multidrug immunosuppressive regimen that includes cyclosporine and corticosteriods
What is the purpose of the immune system?
-To distinguish self from nonself and to protect the body from foreign material (antigens), including cancer
-Defends the body against invading pathogens, foreign antigens, and its own cells that become cancerous, or neoplastic
-Participates in anaphylactic reactions
-Responsible for rejection of kidney, liver, and heart transplants
-Can also sometimes attack itself, causing "autoimmune diseases" or immune-mediated diseases
What are the two types of immunity?
-Humoral immunity: mediated by B lymphocytes
-Cellular immunity: mediated by T lymphocytes
What are immunosuppressants?
-Drugs that decrease or prevent an immune response, thus suppressing the immune system
-Used to prevent or treat rejection of transplanted organs
-Immunosuppressants are used for many immune-related disorders, including rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, multiple sclerosis, myasthenia gravis, psoriasis, and others.
What is the mechanism of action of immunosuppressants?
-All suppress certain T-lymphocyte cell lines, thus preventing their involvement in the immune response
-Results in a pharmacologically immunocompromised state
-Mechanisms of action vary according to drug
What are the major classes of immunosuppressants used to prevent organ rejection?
What is the mechanism of action of corticosteroids?
-Inhibit all stages of T-cell activation and are used for induction, maintenance immunosuppression, and acute rejection
What is the mechanism of action of calcineurin inhibitors?
-Inhibits the phosphate required for interleukin 2 production
What are examples of immunosuppressant drugs?
-glatiramer acetate (Copaxone)
-mycophenolate mofetil (CellCept)
What are indications for immunosuppressants?
-Indications vary from drug to drug
-Primarily indicated for the prevention of organ rejection
What are Muromonab-CD3, mycophenolate, and tacrolimus indicated for?
-both prevention of rejection and treatment of organ rejection
What are Fingolimod and glatiramer indicated for?
-reduction of the frequency of relapses in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis
What are contraindications for immunosuppressants?
-Known drug allergy
-Renal or hepatic failure
-Concurrent radiation therapy
-Pregnancy is not necessarily a contraindication to the use of immunosuppressants but they should be given to pregnant women only in clinically urgent situations
What are adverse effects of immunosuppressants?
-Patients are at increased risk for opportunistic infections
Increase the risk of certain types of cancers, especially skin cancer
What is the main adverse effect associated with cyclosporine and tacrolimus?
What is the main adverse effect associated with corticosteroids, cyclosporine, and tacrolimus?
What do patients taking immunosuppressant drugs need to avoid?
What do immunosuppressant drugs interact with?
-Patients are at an increased risk for drug interactions
-This class of drugs has narrow therapeutic windows; therefore drug interactions can be significant
-Drugs that increase levels of immunosuppressant drugs = toxicity
-Drugs that reduce immunosuppressant drug levels = organ rejection
What is azathioprine (Imuran) used for?
-Prophylaxis of organ rejection concurrently with other immunosuppressant drugs, such as cyclosporine and corticosteroids
-Also used in the treatment of rheumatoid arthritis
What are the adverse effects of azathioprine (Imuran)?
What are basiliximab (Simulect) and daclizumab (Zenapax) used for?
-Used to prevent rejection of transplanted kidneys
-Generally used as part of a multidrug immunosuppressive regimen that includes cyclosporine and corticosteriods
What are the adverse effects of basiliximab (Simulect) and daclizumab (Zenapax)?
-Have a tendency to cause the allergy-like reaction known as cytokine release syndrome
-Cytokine release syndrome
What are patients given to help prevent cytokine release syndrome?
-Corticosteroids (e.g. IV methylprednisolone)
What is cyclosporine (Sandimmune) used for?
-Prevention of organ rejection
-May be used for other autoimmune disorders
What are the adverse effects of cyclosporine (Sandimmune)?
What is tacrolimus (Prograf) used for?
-Used for the prevention of liver transplant rejection
What are adverse effects of tacrolimus (Prograf)?
-Acute renal failure and renal tubular necrosis
Cyclosporine-modified products (e.g. Neoral of Gengraf) are interchangeable with each other but are not interchangeable with what?
-the nurse must be sure to obtain the Sandimmune form of the drug from the pharmacy
How should Cyclosporine be administered?
-Cyclosporine should be given via IV infusion pump and diluted per manufacturer instructions. It is usually diluted with normal saline or 5% dextrose in water.
What is glatiramer acetate (Copaxone) used for?
-Works by blocking T-cell autoimmune activity against myelin protein, which reduces the frequency of the neuromuscular exacerbations associated with multiple sclerosis
Glatiramer acetate (Copaxone) is contraindicated for whom?
-Patients allergic to mannitol
-Mannitol is mixed into the drug
What is muromonab-CD3 (Orthoclone OKT3) used for?
-Reversal and prevention of graft rejection
Muromonab-CD3 (Orthoclone OKT3) is contraindicated in patients with what?
-Hypersensitivity to murine products
-Those experiencing fluid overload
What are adverse effects of muromonab-CD3 (Orthoclone OKT3)?
What is mycophenolate (CellCept) indicated for?
-Indicated for the prevention of organ rejection as well as the treatment of organ rejection
Why does mycophenolate (CellCept) have a FDA black box warning?
-Increased risk of congenital malformations and spontaneous abortions when used during pregnancy
What are common side effects of mycophenolate (CellCept)?
Hypertension occurs in how many patients who take mycophenolate (CellCept)?
-Occurs in 28-77% of patients
What are nursing implications associated with immunosuppressant drugs?
-Monitor WBC counts throughout therapy; if the count drops below normal range, contact the prescriber
-Patients blood work (e.g., CBC, BUN, LDH, AST, ALT and drug specific lab work) should be monitored throughout the treatment
-Oral immunosuppressants should be taken with food to minimize GI upset
-Oral forms are used when possible to decrease the risk of infection that may occur with parenteral injections
-Note that there are several possible drug interactions
-Grapefruit juice also interacts with some of these drugs
-Oral antifungal drugs are usually given with these drugs to treat oral candidiasis that may occur
-Assess the oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx
-Mix oral cyclosporine solution in a glass container
-Do not use Styrofoam containers because the drug adheres to the inside wall of the container
-Inform patients that lifelong therapy with immunosuppressants is indicated with organ transplantation
A male patient who received a kidney transplant 6 months ago is taking cyclosporine. The patient tells the nurse that he has started to take several herbal preparations. Which does not pose a possible problem for the patient?
A. St. John's wort
C. Cat's claw
-Correct answer: B
-Rationale: The potential for interactions between immunosuppressant drugs and herbal preparations should not be overlooked. For example, the enzyme-inducing properties of St. John's wort have been demonstrated to reduce the therapeutic levels of cyclosporine and cause organ rejection. The immunostimulant properties of cat's claw and echinacea may be similarly undesirable in transplant recipients, because they have effects that are opposite those of the immunosuppressants.
The nurse should question the prescriber regarding use of cyclosporine for the treatment of which disease?
C. Irritable bowel disease
D. Multiple sclerosis
-Correct answer: D
-Rationale: Cyclosporine (Sandimmune, Neoral, Gengraf) is an immunosuppressant drug that is indicated for the prevention of organ rejection as well as the treatment of other immunologic disorders, such as various forms of arthritis, psoriasis, and irritable bowel disease.
A patient who had a kidney transplant is receiving cyclosporine PO in maintenance doses. What action would decrease the potency of this drug?
A. Taking it with orange juice
B. Taking it with milk
C. Using a Styrofoam container to administer the drug
D. Mixing it with chocolate milk
-Correct answer: C
-Rationale: Cyclosporine should not be mixed in a Styrofoam container because the medication has been found to adhere to the inside wall of the cup or container.
Which potential problem is of most concern for the patient receiving immunosuppressant drugs?
A. Orthostatic hypotension
B. Increased susceptibility to infections
D. Peripheral edema
-Correct answer: B
-Rationale: Neurotoxicity and edema may be a problem with some immunosuppressants (not orthostatic hypotension), but a heightened susceptibility to opportunistic infections is a major risk factor in immunosuppressed patients.
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