1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 45 Immunosuppressant Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immune System  Defends the body against invading pathogens, foreign antigens, and its own cells that become cancerous  Can also sometimes attack itself, causing “autoimmune diseases” or immune-mediated diseases

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immune System (cont’d)  Participates in anaphylactic reactions  Responsible for rejection of kidney, liver, and heart transplants

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants  Drugs that decrease or prevent an immune response, thus suppressing the immune system  Used to prevent or treat rejection of transplanted organs

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  All suppress certain T-lymphocyte cells lines, preventing their involvement in the immune response  Result: a pharmacologically immunocompromised state  Mechanisms of action vary according to drug

6. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  corticosteroids  Azathioprine  muromonab-CD3  Daclizumab  sirolimus  cyclophosphamide  cyclosporine  tacrolimus  basiliximab  glatiramer acetate

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  Indications vary from drug to drug  Primarily indicated for the prevention of organ rejection  Some also used for immunologic diseases such as rheumatoid arthritis and multiple sclerosis

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d) Muromonab-CD3 is the only drug indicated for reversal of organ rejection once rejection of a transplanted organ has started

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  Newer drugs used to prevent organ transplant rejection  mycophenolate mofetil (CellCept)  daclizumab (Zenapax)*  basiliximab (Simulect)*  sirolimus (Rapamune) *Note that these drugs are also monoclonal antibodies (MABs)

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  azathioprine (Imuran)  Used as an adjunct medication to prevent rejection of kidney transplants  Also used in the treatment of rheumatoid arthritis

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  cyclosporine (Cyclosporin A)  Primary drug used in the prevention of kidney, liver, heart, and bone marrow transplant rejection  May be used for other autoimmune disorders  tacrolimus (Prograf)  Used only for the prevention of liver transplant rejection  Others uses are unlabeled uses

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  glatiramer acetate (Copaxome)  The only immunosuppressant drug used for the treatment of multiple sclerosis (MS)  Used to reduce the frequency of MS relapses (exacerbations) in relapsing-remitting multiple sclerosis (RRMS)

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Immunosuppressants (cont’d)  Adverse effects vary according to drugs, and may be devastating **All immunosuppressed patients have a heightened susceptibility to opportunistic infections**

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Thorough assessment should be performed before administering these drugs  Renal, liver, and cardiovascular function studies  CNS baseline function  Respiratory assessment  Baseline vital signs  Baseline laboratory studies, including hemoglobin, hematocrit, WBC, and platelet counts

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Assess for contraindications, drug allergies, drug interactions  Monitor WBC counts throughout therapy; if the count drops below 3000/mm 3 the drug should be discontinued, but only after contacting the physician

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Oral antifungal drugs are usually given with these drugs to treat oral candidiasis that may occur  Observe the oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Oral cyclosporine solution must be mixed in a glass container  Styrofoam containers should not be used because the drug adheres to the inside wall of the container

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Follow guidelines for parenteral administration carefully  Patients need to be told that lifelong therapy with immunosuppressants is indicated with organ transplantation

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Patients taking immunosuppressants should be encouraged to take measures to reduce the risk of infection  Avoiding crowds  Avoiding people with colds or other infections  Patients should be told to report any fever, sore throat, chills, joint pain, fatigue, or other signs of a severe infection immediately

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor for therapeutic responses  Monitor for adverse effects and signs of drug toxicity