Biologic agents: Nursing pharmacology

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 IL1 inhibitors like Anakinra, interleukin 6 or IL-6 inhibitors like tosillizumab, and interleukin 17A or IL-17A inhibitors like secukinumab.

These biologic agents are administered subcutaneously, and as their name suggests, the way they work is by inhibiting their respective inflammatory cytokines.

So TNF, IL1, IL6, 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 box 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 anti-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 anti-nuclear 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's disease.

Then ensure emergency equipment is readily available in case a hypersensitivity reaction to the medication occurs. Calculate the prescribed dose in milliliters per hour, confirm your IV tubing has an inline 1.2 micron filter, and start an infusion of 0.9% normal saline.

Now, 90 minutes prior to starting the biologic agent, be sure to pre-medicate your client with diphenhydramine and acetaminophen as ordered.

If your client has had an infusion reaction to a previous infusion of the biologic agent, also premedicate with the ordered dexamethasone.

During the infusion, monitor your client's temperature, BP, SPO2, pulse, and respiratory rate every 15 minutes for the first hour and every 30 minutes for the second hour.

Continue to monitor for an infusion reaction as the medication is infused, and for 1 hour after the infusion is complete.

Keep an eye out for the development of worrisome signs and symptoms, such as systolic BP of less than 90 millimeters of mercury or greater than 160 millimeters of mercury, a pulse less than 60 BPM or greater than 120 BPM, as well as a temperature more than 101 °F or 38.3 °C, along with the appearance of an itchy rash or a client report of swelling in the throat and difficulty breathing.

If your client develops any of these symptoms, stop the infusion and immediately report them. After the infusion is complete, teach your client to report symptoms of hepatotoxicity, like abdominal pain, vomiting, anorexia, or dark urine.

Advise them to use preventative measures such as hand hygiene and avoiding crowded areas, and to report symptoms of infection like fever, chills, tachycardia, sore throat, cough, congestion, and dysuria.

Also, instruct them to report signs of new onset of heart failure, including shortness of breath, fatigue, and swelling in the legs and feet.

Remind them to monitor themselves for skin changes that could indicate a malignancy or a reaction to the medication. In addition, be sure to instruct your client to avoid getting any live virus vaccines, such as the measles, mumps, and rubella, or MMR vaccine during therapy.

Lastly, instruct female clients to use reliable contraception while being treated with biologic agents. Alright, as a quick recap, biologic agents are medications used to treat inflammatory disorders like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis, and Crohn's disease.

These medications can be broken down into two main classes, tumor necrosis factor or TNF blockers, and interleukin or IL inhibitors.

A major side effect is bone marrow suppression, which can put the client at increased risk of infection. Additionally, TNF blockers can cause headaches and demyelination of the nervous system, as well as stroke, myocardial infarction, heart failure, hypotension, and hypersensitivity reactions.

While IL inhibitors might lead to arthralgia and gastrointestinal disturbances. When caring for a client prescribed a biologic agent, nursing considerations include performing a baseline assessment, as well as monitoring for therapeutic and side effects.

Client teaching is focused on the purpose of the medication and recognition of side effects to report.