Immunosuppressants for autoimmune diseases: Nursing pharmacology

Autoimmune diseases occur when the immune system mistakenly attacks various tissues and organs around the body, such as in systemic lupus erythematosus and rheumatoid arthritis.

Often there are periods of illness, called flares, and periods of remission during which there are few or no symptoms. Unfortunately, autoimmune diseases can’t be cured, but their symptoms can be treated with a variety of systemic immunosuppressant medications.

Okay, immunosuppressants to treat autoimmune diseases include corticosteroids like prednisone or dexamethasone, monoclonal antibodies like belimumab, immunomodulators like azathioprine, antimetabolites like methotrexate, and antimalarials like hydroxychloroquine.

These medications can be taken orally, or injected as intravenously, intramuscularly, or less commonly, subcutaneously. Once administered, immunosuppressants primarily work by blunting the inflammatory process so that it can’t cause damage to healthy tissues, and preventing or limiting the severity of flares.Unfortunately, some of these medications can also increase the risk of side effects like bone marrow suppression, which can lead to anemia, thrombocytopenia, and leukopenia, as well as increased risk for infections.

Some clients may also experience drowsiness, fatigue, and gastrointestinal disturbances, such as anorexia, nausea, vomiting, and diarrhea.

Also, if administered by injection, they can cause infusion or injection site reactions. Now, corticosteroids can also lead to symptoms of hypercortisolism, such as acne, mood changes, muscle weakness, hyperglycemia, and weight gain, predominantly in the trunk and face, respectively termed buffalo hump and moon facies.

Additionally, prolonged use of corticosteroids can increase the risk of osteoporosis and pathological fractures. On the other hand, belimumab can often cause headaches, depression, insomnia, and some clients may even experience suicidal ideation.

Clients on azathioprine may develop alopecia, skin rash, vision problems, as well as stomatitis, and hepatotoxicity. In addition, azathioprine has a boxed warning for increasing the risk of cancer.

Methotrexate can also lead to alopecia, photosensitivity, ulcerative stomatitis or painful mouth ulcers, as well as pulmonary fibrosis, hepatotoxicity, nephrotoxicity, and hyperuricemia.

Hydroxychloroquine’s most common side effects are visual and hearing changes. In addition, clients may develop a skin rash, photosensitivity, and hypersensitivity reactions like Stevens Johnson syndrome and drug reaction with eosinophilia and systemic symptoms or DRESS for short.

Finally, some clients may also experience neurological side effects, such as headaches, nightmares, and even seizures, as well as cardiovascular side effects like heart failure, QT prolongation, and torsade de pointes.

As far as contraindications go, immunosuppressants should generally be avoided during pregnancy and breastfeeding, as well as in clients with active infections, or bone marrow suppression.

Additionally, corticosteroids should be used with caution in clients with glaucoma, peptic ulcer disease, heart failure, diabetes mellitus, osteoporosis, or certain psychiatric conditions.

In addition, methotrexate has a boxed warning for use in clients with pulmonary, hepatic or renal disease, and lymphoma, as well as in clients undergoing radiation therapy.

Methotrexate has another important boxed warning against its concomitant use with certain NSAIDs, since the combination may result in gastrointestinal toxicity.

Finally, hydroxychloroquine is contraindicated in clients with hepatic or renal disease, as well as in those with myasthenia gravis, which might be exacerbated.Now, when a client with systemic lupus erythematosus is prescribed hydroxychloroquine, first perform a baseline assessment of their vital signs and symptoms, including fatigue, fever, muscle and joint pain, as well as the presence of skin lesions, edema in the lower extremities, and other alterations in body function.

Then, review their laboratory test results for CBC, ESR, CRP, ANA, renal and hepatic function, and urinalysis, as well as diagnostic test results, such as imaging studies, ECG, and ophthalmologic exam.

Next, explain to your client that the medication will help reduce their inflammation, which will in turn help decrease some of their symptoms, decrease the amount of flares they experience, and reduce organ damage caused by the disease.

Then, instruct your client to take their medication with food or milk to reduce gastrointestinal upset, and remind them to avoid consuming alcohol during therapy.

Be sure to explain that it may take several weeks before they start to feel better, and encourage them to continue to take the medication exactly as prescribed.

If they miss a dose, advise them to take their medication as soon as they remember, unless it is almost time for their next dose; and emphasize the importance of never taking a double dose to make up for the one they missed.

Then, let your client know that the drug can cause side effects like photophobia and photosensitivity, and encourage them to wear sunglasses, use sunscreen, and wear long-sleeved clothes when they are outside.

Also, let them know that the medication may cause their urine to turn a rusty brown color. Then, teach your client about symptoms that should be immediately reported to their healthcare provider, such as visual changes like light sensitivity, blurry vision, or difficulty reading; auditory changes like difficulty hearing or ringing in the ears; skin changes like an unusual rash or blistering; as well as symptoms that might be indicative of hematologic abnormalities, which could manifest as unusual bleeding or bruising, as well as symptoms of infection such as fever or sore throat, and symptoms of heart conduction problems, such as palpitations or feeling an irregular heartbeat.

Lastly, remind your client that routine ophthalmologic exams are needed while taking hydroxychloroquine. Finally, during the course of therapy, be sure to closely monitor your client’s periodic laboratory test results, ECG, and their ophthalmologic exams; and evaluate for the desired therapeutic effects of an improvement in symptoms, decreased disease-related organ damage, and a report of fewer disease flares.

All right, as a quick recap… Autoimmune diseases occur when the immune system mistakenly attacks various tissues and organs around the body, and can be treated with immunosuppressant medications, such as corticosteroids, antimetabolites, or antimalarials.

Immunosuppressants work by blunting the inflammatory process, and preventing or limiting the severity of flares. Side effects include bone marrow suppression, which leads to anemia, thrombocytopenia, and leukopenia, increasing the risk of infection.

Other side effects include nausea and vomiting, stomatitis, alopecia, photosensitivity, as well as more serious side effects such as Stevens Johnson Syndrome.

Nursing considerations include performing a baseline assessment, and monitoring for side effects and the desired therapeutic effect.

Client education is focused on safe self-administration, and recognizing side effects that need to be reported to