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Biologic agents: Nursing Pharmacology

Notes

Notes

BIOLOGIC AGENTS, PART 1
DRUG NAME
etanercept (Enbrel), infliximab (Remicade, Renflexis, 
Avsola, Inflectra), adalimumab (Humira)
CLASS
TNF blockers
MECHANISM OF ACTION
Prevent TNF from attaching to its receptor → suppress immune response
INDICATIONS
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Psoriasis
  • Crohn disease
ROUTE(S) OF ADMINISTRATION
  • SubQ
SIDE EFFECTS
  • Bone marrow suppression (increased risk of infections)
  • Skin rash
  • Injection site reactions
  • Headaches
  • Nervous system demyelination
  • Stroke
  • Myocardial infarction
  • Heart failure
  • Hypotension
CONTRAINDICATIONS AND CAUTIONS
  • Pregnancy
  • Breastfeeding
  • Active infection
  • Boxed warning: tuberculosis, hepatitis B, and invasive fungal infections
  • Demyelinating disorders
  • Heart failure
BIOLOGIC AGENTS, PART 2
DRUG NAME
anakinra (Kineret)
tocilizumab (Actemra, Actemra ACTPen)
secukinumab (Cosentyx, Cosentyx Sensoready Pen)
CLASS
IL-1 inhibitor
IL-6 inhibitor
IL-17A inhibitor
MECHANISM OF ACTION
Prevent IL-1, IL-6, or IL-17A from attaching to their receptors → suppress immune response
INDICATIONS
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Psoriasis
  • Crohn disease
ROUTE(S) OF ADMINISTRATION
  • SubQ
SIDE EFFECTS
  • Bone marrow suppression (increased risk of infections)
  • Skin rash
  • Injection site reactions
  • Arthralgia
  • Nausea, vomiting, diarrhea
CONTRAINDICATIONS AND CAUTIONS
  • Pregnancy
  • Breastfeeding
  • Active infection
  • Boxed warning: tuberculosis, hepatitis B, and invasive fungal infections
  • Hepatic or renal disease
  • Immunosuppression
  • Neoplastic disease
NURSING CONSIDERATIONS: BIOLOGIC AGENTS
ASSESSMENT AND MONITORING
Infliximab for Crohn disease
Assessment
  • Baseline assessment; e.g., current symptoms, bowel habits, nutritional status
  • Weight
  • Vital signs
  • SpO2
  • Laboratory test results
    • CBC
    • Liver function tests
    • BUN, creatinine
    • ANA titer
    • Negative TB and HBV; no current infections
  • Immunizations up to date

Interventions and monitoring
  • Ensure emergency equipment is readily available
  • Calculate prescribed dose in mL/hr
  • IV tubing with in-line 1.2 micron filter
  • Start 0.9% normal saline infusion
  • Premedicate with diphenhydramine and acetaminophen 90 minutes before infliximab infusion
    • Add dexamethasone or prednisone for previous infusion reaction
  • Monitor during infusion: temperature, blood pressure, SpO2, pulse and respiratory rate every 15 minutes for 1st hour, every 30 minutes for the second hour, and stop infusion and immediately report: systolic blood pressure of less than 90 mmHg or greater than 160 mmHg; pulse less than 60 beats per minute or greater than 120 beats per minute; temperature more than 101 F, or 38.3 C, appearance of an itchy rash or a client report of swelling in the throat and difficulty breathing
  • Monitor after infusion: continue monitoring one hour after infusion is complete
CLIENT EDUCATION
  • Report symptoms of hepatotoxicity; e.g., abdominal pain, vomiting, anorexia, dark urine
  • Measures to prevent infection; e.g., hand hygiene; avoid crowded areas
  • Report symptoms of infection; e.g., fever, chills, tachycardia, sore throat, cough, congestion, dysuria
  • Report signs of new onset of heart failure; e.g., shortness of breath, fatigue, swelling in the legs and feet
  • Report skin changes that could indicate malignancy or medication reaction
  • Avoid getting live-virus vaccines
  • Female clients: use reliable contraception
Transcript

Biologic agents are a group of medications used to treat various inflammatory conditions, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis, and Crohn’s disease.

Now, biologic agents can be broken down into two main classes: tumor necrosis factor, or TNF blockers, which include etanercept, infliximab, and adalimumab; and interleukin inhibitors, which include interleukin- 1 or IL-1 inhibitors, like anakinra, interleukin- 6, or IL-6 inhibitors, like tocilizumab, and interleukin- 17A, or IL-17A inhibitors, like secukinumab.

These biologic agents are administered subcutaneously, and as their names suggest, the way they work is by inhibiting their respective inflammatory cytokines, so TNF, IL-1, IL-6, or IL-17A, ultimately preventing them from attaching to their receptors.

As a result, these medications help suppress the immune response in clients with inflammatory conditions.

Now, clients on biologic agents might develop a skin rash or injection site reactions, such as erythema, mild pain, and discomfort.

A major side effect of biologic agents is bone marrow suppression, which can put the client at increased risk of infection.

In fact, most TNF blockers have a boxed warning for the development of severe infections, such as tuberculosis, as well as lymphoma and other neoplastic diseases.

Additionally, TNF blockers have been associated with headaches and demyelination of the nervous system, as well as myocardial infarction, heart failure, stroke, hypotension, and some clients may develop hypersensitivity reactions, such as Stevens Johnson syndrome or toxic epidermal necrolysis.

In contrast, interleukin inhibitors might lead to arthralgia and gastrointestinal disturbances, such as nausea, vomiting, or diarrhea.

As far as contraindications go, biologic agents should be used with caution during pregnancy and breastfeeding, as well as in children and elderly clients.

In addition, they are contraindicated in clients with an active infection or sepsis. In particular, most of these medications have a boxed warning for use in clients with infections like tuberculosis, hepatitis B, and invasive fungal infections.

TNF blockers should also be used with caution in clients with seizures or demyelinating disorders like multiple sclerosis, and are contraindicated in those with heart failure; while interleukin inhibitors should be used with caution in clients with hepatic or renal disease, immunosuppression, or neoplastic disease.

Now, if a client with an inflammatory condition, such as Crohn’s disease, is prescribed a biologic agent, such as the TNF blocker infliximab, first perform a baseline assessment of their current symptoms, bowel habits, and nutritional status.

Next, assess your client’s weight, vital signs, and SpO2. In addition, review their laboratory test results, including CBC, liver function tests, BUN, creatinine, and antinuclear antibody or ANA titer; also, be sure to confirm that the client doesn’t currently have an active infection, especially tuberculosis, hepatitis B, and invasive fungal infections.

Lastly, review their medical record to ensure all of their immunizations are up to date before administering a biologic agent.

Before administration, explain to your client how the medication works to help decrease their inflammatory symptoms, such as bowel pain and cramping for those with Crohn disease.

Then, ensure emergency equipment is readily available in case a hypersensitivity reaction to the medication occurs.

Calculate the prescribed dose in mL/hr, confirm your IV tubing has an in-line 1.2 micron filter, and start an infusion of 0.9% normal saline.

Sources
  1. "Focus on Nursing Pharmacology" LWW (2019)
  2. "Pharmacology" Elsevier Health Sciences (2014)
  3. "Mosby's 2021 Nursing Drug Reference" Mosby (2020)
  4. "Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2016)
  5. "Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)
  6. "Lehne's Pharmacology for Nursing Care" Elsevier Health Sciences (2014)