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Immunosuppressants to treat autoimmune diseases: Nursing Pharmacology

Notes

Notes

IMMUNOSUPPRESSANTS TO TREAT AUTOIMMUNE DISEASES
DRUG NAME
prednisone, dexamethasone
belimumab, azathioprine, methotrexate, hydroxychloroquine
CLASS
Systemic corticosteroids
Immunosuppressants
MECHANISM OF ACTION
Blunt inflammatory process → prevent and limit severity of flares → limit organ damage
INDICATIONS
Rheumatoid arthritis, systemic lupus erythematosus, other autoimmune diseases
ROUTE(S) OF ADMINISTRATION
  • PO
  • IM
  • IV
  • PO
  • IM
  • IV
  • SubQ
SIDE EFFECTS
  • Bone marrow suppression
  • Increased risk for infections
  • Drowsiness
  • Fatigue
  • Nausea
  • Injection site reactions
  • Acne
  • Mood changes
  • Muscle weakness
  • Hyperglycemia
  • Weight gain (face and trunk)
  • Osteoporosis, pathological fractures
  • Auditory and visual changes
  • Cardiotoxicity
  • Hepatotoxicity
  • Nausea, vomiting, diarrhea
  • Suicidal ideations
  • Alopecia
  • Photosensitivity
  • Hypersensitivity reactions (e.g., Stevens-Johnson syndrome)
CONTRAINDICATIONS AND CAUTIONS
  • Active infections
  • Bone marrow suppression
  • Glaucoma
  • Peptic ulcer disease
  • Heart failure
  • Diabetes mellitus
  • Osteoporosis
  • Certain psychiatric conditions
  • Active infections
  • Bone marrow suppression
  • Pregnancy (boxed warning for methotrexate)
  • Breastfeeding
NURSING CONSIDERATIONS:
IMMUNOSUPPRESSANTS TO TREAT AUTOIMMUNE DISEASES
DRUG NAME
hydroxychloroquine for SLE
ASSESSMENT AND MONITORING
Assessment
  • Vital signs, current symptoms
  • Laboratory test results: renal and hepatic function, CBC, ANA, ESR, CRP, urinalysis
  • Diagnostic test results: imaging studies, ECG, ophthalmologic exam

Monitoring
  • Periodic laboratory test results, ECG, ophthalmologic exam results
  • Evaluation: improvement in symptoms, a report of fewer disease flares, and decreased disease-related organ damage
CLIENT EDUCATION
  • Purpose of medication: help reduce pain and inflammation, decrease symptoms, decrease flares, reduce organ damage
  • Take their medication with food or milk
  • May take several weeks before they start to feel better
  • Take the medication exactly as prescribed; if dose is missed, do not double doses
  • Avoid alcohol during therapy
  • Side effects
    • Photophobia, photosensitivity
    • Urine to turn a rusty brown color
    • Immediately report changes to vision, hearing, skin; hematological problems
    • Routine ophthalmologic exams are required
Transcript

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.

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)