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Nonbiologic DMARD therapy: Nursing Pharmacology

Notes

Notes

NONBIOLOGIC DMARD THERAPY, PART 1
DRUG NAME
hydroxychloroquine (Plaquenil)
azathioprine 
(Azasan, Imuran)
*High Alert Medication*
CLASS
Nonbiologic disease modifying antirheumatic drugs (DMARDs)
MECHANISM OF ACTION
Suppress the inflammatory response and block the proliferation of rapidly dividing cells
INDICATIONS
  • Rheumatoid arthritis
  • Juvenile idiopathic arthritis
  • Malaria
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Atopic dermatitis
  • Inflammatory bowel disease
  • Cancer
  • Renal transplant recipients
ROUTE(S) OF ADMINISTRATION
  • PO
  • IV
  • IM
  • SubQ
  • PO
  • IV

SIDE EFFECTS
  • Bone marrow depression: leukopenia, increased risk for infections
  • Gastrointestinal disturbances: anorexia, nausea, vomiting, diarrhea
  • Alopecia, skin rash, photosensitivity
  • Hypersensitivity reactions
  • Vision problems due to corneal or retinal damage
  • Hearing difficulties due to ototoxicity
  • Headaches, nightmares, seizures
  • Heart failure, QT prolongation, torsades de pointes
  • Alopecia
  • Skin rash
  • Vision problems due to retinopathy
  • Stomatitis
  • Hepatotoxicity
  • Boxed warning: risk of cancer
CONTRAINDICATIONS AND CAUTIONS
  • Pregnancy
  • Breastfeeding
  • Hepatic or renal disease
  • Myasthenia gravis
  • Pregnancy
  • Breastfeeding

NONBIOLOGIC DMARD THERAPY, PART 2
DRUG NAME
sulfasalazine (Azulfidine)
methotrexate (Otrexup, Rasuvo, Trexall, Xatmep)
*High Alert Medication*
CLASS
Nonbiologic disease modifying antirheumatic drugs (DMARDs)
MECHANISM OF ACTION
Suppress the inflammatory response and block the proliferation of rapidly dividing cells
INDICATIONS
  • Rheumatoid arthritis
  • Inflammatory bowel disease
  • HIV infection
  • Rheumatoid arthritis
  • Psoriasis
  • Cancer
  • Medical abortion, such as in the case of an ectopic pregnancy
ROUTE(S) OF ADMINISTRATION
  • PO
  • PO
  • IV
  • IM
  • SubQ
SIDE EFFECTS
  • Skin rash
  • Photosensitivity
  • Hypersensitivity reactions, anaphylaxis
  • Stomatitis
  • Yellow-orange discoloration of the urine
  • Alopecia
  • Photosensitivity
  • Ulcerative stomatitis
  • Pulmonary fibrosis
  • Hepatotoxicity
  • Nephrotoxicity
  • Hyperuricemia
CONTRAINDICATIONS AND CAUTIONS
  • Pregnancy
  • Breastfeeding
  • Gastrointestinal or urinary obstruction
  • Porphyria
  • Boxed warning: pregnancy, bone marrow suppression, pulmonary, hepatic or renal disease, active infection, lymphoma, clients undergoing radiation therapy, concomitant NSAID use
  • Breastfeeding
  • Leukopenia
  • Thrombocytopenia
  • Anemia
  • AIDS
  • Chronic liver disease
  • Alcoholism
NURSING CONSIDERATIONS: NONBIOLOGIC DMARD THERAPY
ASSESSMENT AND MONITORING
Methotrexate
Assessment
  • Musculoskeletal assessment: pain, stiffness, joint swelling, range of motion
  • Laboratory test results: renal and hepatic function, CBC, rheumatoid factor, CRP and ESR; confirm negative pregnancy test for female clients of childbearing age
  • Diagnostic test results: X-ray, ultrasound

Monitoring
  • Laboratory test results
  • Side effects
  • Therapeutic effects: decreased joint inflammation and pain; increased functionality
CLIENT EDUCATION
  • Purpose of medication: help to decrease joint pain and inflammation; increase functionality
  • Take their medication exactly as prescribed, once each week, on the same day of the week
    • PO liquid: measure using a calibrated oral syringe
    • Subcutaneous: single-use autoinjector
      • Inject into thigh or abdomen, two inches away from their navel
      • Rotate the injection sites
      • Avoid bruised, broken, tender areas
      • Dispose of equipment properly
    • If they miss a dose, contact healthcare provider for directions
  • Take the prescribed folic acid supplement daily
  • Use reliable form of birth control; notify healthcare provider of pregnancy
  • Lifestyle modifications
    • Increase fluid intake up to two liters per day
    • Avoid alcohol
    • Include foods high in folic acid in daily diet; e.g., spinach, romaine lettuce, broccoli, peanuts, oranges, and whole grains
    • Infection control measures
      • Hand hygiene techniques
      • Avoid live virus vaccines, large crowds, people with infections
    • Use sunscreen and protective clothing when spending time outdoors
  • Recognize signs and symptoms of important side effects to report
    • Respiratory: dry, non-productive cough or shortness of breath
    • Gastrointestinal: fatigue, anorexia, upper right abdominal pain, dark urine, or yellowing of the skin or eyes
    • Renal: decreased urine output, blood in the urine, significant weight gain
    • Hematologic: dark, tarry stools, coughing up blood, or emesis that looks like coffee grounds, bleeding gums, nose bleeds, minor cuts that take an unusually long time to stop bleeding
    • Neurologic: confusion, weakness, loss of coordination
    • Skin: rash, blisters, peeling skin, sores in the mouth, nose, or eyes
    • Immune: fever, chills, sore throat, cough, large amounts of sputum
Transcript

Nonbiologic disease modifying antirheumatic drugs, or DMARDs for short, are a group of medications primarily used to treat rheumatoid arthritis. The most commonly used ones are methotrexate, azathioprine, sulfasalazine, and hydroxychloroquine. Now, in addition to rheumatoid arthritis, each of these medications has its own set of indications. So, methotrexate can be used to treat psoriasis, inflammatory bowel disease or IBD, and certain cancers. Azathioprine can be also given to clients who have received a renal transplant to prevent rejection. Sulfasalazine is also indicated for IBD and HIV infection. Finally, hydroxychloroquine can be also used to treat malaria, systemic lupus erythematosus, and even some forms of arthritis, such as rheumatoid arthritis and juvenile idiopathic arthritis.

Now, nonbiologic DMARDs can be administered orally, subcutaneously, intramuscularly, and intravenously. Once administered, they mainly work by inhibiting the immune response and blocking the proliferation of endothelial cells and fibroblasts at the involved joints, slowing the progression of rheumatoid arthritis.

However, nonbiologic DMARDs can cause some notable side effects, such as bone marrow depression, which can lead to leukopenia and increased risk for infections. Other general side effects include gastrointestinal disturbances, such as anorexia, nausea, vomiting, and diarrhea.

More specifically, methotrexate can also lead to alopecia, photosensitivity, ulcerative stomatitis or painful mouth ulcers, as well as pulmonary fibrosis, hepatotoxicity, and nephrotoxicity. On the other hand, clients on azathioprine may develop alopecia, skin rash, vision problems due to retinopathy, as well as stomatitis, and hepatotoxicity. In addition, azathioprine has a boxed warning for increasing the risk of cancer.

Next, sulfasalazine can result in a skin rash, photosensitivity, and hypersensitivity reactions like Stevens-Johnson syndrome, or anaphylaxis, as well as stomatitis, and orange discoloration of the urine.

Finally, hydroxychloroquine’s most common side effects are vision problems due to corneal or retinal damage, and hearing difficulties due to ototoxicity. In addition, clients may develop alopecia, 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, methotrexate is contraindicated in cases of leukopenia, thrombocytopenia, anemia, AIDS, chronic liver disease, and alcoholism. In addition, methotrexate has boxed warnings for bone marrow suppression, pulmonary, hepatic, renal, and dermatologic toxicity, as well as for its potential to increase the risk of opportunistic infections. Methotrexate has other important boxed warnings against its concomitant use with certain NSAIDs, since the combination may result in gastrointestinal toxicity, as well as its use during pregnancy, while precautions should be taken during breastfeeding. Lastly, methotrexate can cause neurotoxicity, which could be manifested by loss of coordination, difficulty thinking and speaking, or seizures.

On the other hand, azathioprine is contraindicated during pregnancy and breastfeeding, while sulfasalazine and hydroxychloroquine should be used with caution. Now, sulfasalazine is contraindicated for use in clients with gastrointestinal or urinary obstruction, or porphyria. 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 your client with rheumatoid arthritis is prescribed a nonbiologic DMARD agent like methotrexate, first perform a focused baseline musculoskeletal assessment, checking for joint pain, stiffness, swelling, and range of motion. Then, review their most recent laboratory test results, including renal and hepatic function, CBC, rheumatoid factor, CRP and ESR; and be sure to confirm a negative pregnancy test for female clients of childbearing age. Lastly, review diagnostic test results, including X-rays and ultrasound.

Next, explain to your client how their medication will help to decrease their joint pain and inflammation as well as increase their day-to-day functionality. Instruct them to take their medication exactly as prescribed, once each week, on the same day of the week. If your client is taking the medication orally, be sure to demonstrate how to measure the correct dose using a calibrated oral syringe.