Ch. 11 Drugs That Affect the Immune System

A child who weighs 78 lb is prescribed to receive azathioprine (Imuran) 2 mg/kg intravenously. The solution available is azathioprine 100 mg/10 mL. How many milliliters will you prepare for a correct dose?

ANS: 7.1 1 kg = 2.2 lb. Child's weight in kilogram = 35.4 (78/2.2 = 35.4). 35.44 kg multiplied by 2 mg/kg = 70.8 mg. Drug on hand is Azathioprine 100 mg/10 mL. Obtain the 1 mL dose by dividing 100 mg by 10 mL to get 10 mg/1 mL. Divide 70.8 mg by 10mg/mL to get 7.08 mL round up to 7.1 mL.

Which statement regarding artificially acquired active immunity is true? a. It requires "boosting" on a regular schedule. b. It is present in only children and not in adults. c. It can be used for vaccinations but not for immunizations. d. It has the shortest duration of effectiveness of any type of immunity.

ANS: A Artificially acquired active immunity is long-lasting but requires boosting on a specific schedule to remain effective. This type of immunity can develop in adults as well as in children.

Why is a person who has already had chickenpox considered to be "immune" to developing the disease again even if he or she is heavily reexposed to the virus again? a. On reexposure to the came virus, his or her sensitized B lymphocytes generate large amounts of antichickenpox antibodies. b. This person's neutrophils and macrophages are able to recognize the virus sooner and make antibodies against it. c. Once a person has had chickenpox, the virus can never enter his or her body again. d. He or she has developed naturally acquired passive immunity to the virus.

ANS: A Once B lymphocytes (B cells) have learned to recognize the virus that caused chickenpox, those cells and all of the progeny from those cells are capable of really speeding up production of antichickenpox antibodies on reexposure, which inactivates the viruses or eliminates them before the person gets sick with the disease.

Which patient is most likely to be taking azathioprine (Imuran) as a single agent daily instead of combination selective immunosuppressant therapy? a. 30-year-old with rheumatoid arthritis b. 35-year-old experiencing an acute rejection episode after a heart transplant c. 50-year-old who received a donated kidney in a transplant 3 years ago d. 70-year-old who has colon cancer that has metastasized to the liver

ANS: A Therapy for transplant maintenance and antirejection drug therapy requires a combination of at least three different types of antirejection drugs. Metastatic colon cancer is not treated with azathioprine. Depending on the type and severity of an autoimmune disorder, it is most often treated or managed with single agent therapy.

A patient whose foot was cut deeply by a rusty tin can last received a tetanus toxoid vaccination 8 years ago. He is prescribed to now receive a tetanus toxoid injection. What type of immunity does this vaccination help provide? a. Boosting of artificially acquired active immunity b. Initiation of artificially acquired active immunity c. Boosting of naturally acquired active immunity d. Initiation of naturally acquired active immunity

ANS: A This patient has received tetanus toxoid vaccinations in the past. Any vaccination is an artificial delivery of a substance that can trigger immunity. The fact that it is a toxoid and not an antibody means that the patient's body has actively produced antibodies in the past. By giving the patient more of the toxoid, the patient's own immunity to tetanus is being "boosted."

Which classes of antirejection and immunosuppressant drugs are included as standard, daily, antirejection drug therapy after a kidney transplant? a. Antiproliferatives b. Calcineurin inhibitors c. Cytotoxic agents d. Corticosteroids e. Monoclonal antibodies f. Polyclonal antibodies

ANS: A, B, D The three classes of drugs used together on a daily basis to prevent kidney rejection after transplantation are one type of corticosteroids, a drug from the calcineurin inhibitor class, and a drug from the antiproliferative class. Cytotoxic drugs are rarely used for antirejection therapy. Monoclonal antibodies are used only initially. Polyclonal antibodies are used short term to treat an acute rejection episode.

Which information should you document after vaccinating a patient with the seasonal influenza vaccine? a. Age of the patient b. Color of the vaccine c. Condition of the site d. Expiration date on the vaccine vial e. Insurance type f. Name of the patient g. Needle length and diameter h. Site of vaccination

ANS: A, C, D, F, H The information required to be documented in the patient's medical record or permanent log for vaccination includes the age and name of the patient; name of the vaccine; manufacturer, lot number, and expiration date of the vaccine; dosage of the vaccine; site of the vaccination; and condition of the side.

What is definition of a toxoid that can be used for vaccination? a. A vaccine containing antibodies that were produced by other animals in response to the administration of human white blood cells. b. A vaccine that contains a modified toxin that an organism produces or a small part of the actual organism. c. A vaccine designed to be toxic to or inhibit the excessive functioning of the immune system. d. A vaccine that contains artificially created antibodies that will generate passive immunity.

ANS: B A toxoid is a vaccine, not an antibody, that contains either a modified toxin an organism produces or a small part of the actual organism. It does not contain any type of antibodies and does not inhibit immune functioning.

A child is receiving a seasonal influenza vaccination administered by nasal inhalation. What type of immunity is expected to develop as a result of this vaccination method? a. Artificially acquired passive immunity b. Artificially acquired active immunity c. Naturally acquired passive immunity d. Naturally acquired active immunity

ANS: B Although most vaccines are injected, some are swallowed orally (such as the oral polio vaccine) and others are inhaled nasally. Regardless of how the vaccine is delivered, it is artificial rather than natural because it is deliberately placed in a person's body with the intent of triggering immunity. Because it is a vaccine rather than preformed antibodies, the person's own immune system must take an active part in generating sufficient antibodies to provide full immunity.

Which precaution is most important to teach a patient taking an antiproliferative agent to manage an autoimmune disease? a. Do not stop taking this drug for any reason or your organs will become atrophied. b. Keep all health care appointments because your risk for cancer is now increased. c. Avoid foods and drinks containing caffeine because your risk for high blood pressure is greatly increased. d. Make certain someone is with you when you take this drug because allergic reactions are common and often delayed.

ANS: B Antiproliferative drugs suppress bone marrow production of the lymphocytes that provide immunosurveillance against cancer. Anyone taking these drugs long term has a higher risk for cancer development and should be monitored regularly.

Which antirejection drug works by inhibiting the mTOR pathway? a. Azathioprine (Imuran) b. Everolimus (Zortress) c. Tacrolimus (Prograf) d. Daclizumab (Zenapax)

ANS: B Everlolimus is a drug from the antiproliferative class that interferes with T lymphocytes being able to complete the cell cycle for cell division by blocking the mTOR signal transduction pathways.

Which condition would be a contraindication for giving RhoGam to an Rh-negative mother? a. Having an allergy to peanuts and penicillin b. Giving birth to an Rh-negative infant c. Receiving a blood transfusion after delivery d. Giving birth to twins

ANS: B RhoGam allows any antiRh antibodies produced by an Rh-negative mother against an Rh-positive fetus/infant's blood to be eliminated from her body. An Rh-negative fetus/infant would not trigger the mother to synthesize antiRh antibodies. Because RhoGam is not made from peanuts or penicillin, an allergy to these substances is not a contraindication to its use. Blood transfusions are not a contraindication for RhoGam and neither is the birth of twins (unless they both are Rh-negative).

Which action is essential to detect a common side effect after giving a calcineurin inhibitor? a. Keep accurate intake and output records. b. Check blood pressure every 4 to 8 hours. c. Compare the patient's lower legs for swelling or redness. d. Carefully check the patient for yellowing of skin or sclera.

ANS: B The most common side effects of the calcineurin inhibitors are hypertension, elevated serum cholesterol levels, and hyperglycemia.

A 75-year-old patient tells you he is not planning to receive a "flu shot" this year because he had one just a year ago. What is your best response? a. "Because you are older and your immune system is more fragile, you should have one this year too as a booster." b. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." c. "The "flu shot" you had last year should still protect you for seasonal influenza, but you still need a vaccination for H1N1." d. "The fact that you have been vaccinated by injection just last year makes you a candidate to use the nasal vaccination this year."

ANS: B The seasonal influenza vaccine is composed of three or four different types of viral antigens that are thought by the Centers for Disease Control and Prevention to be the ones most likely to be prevalent during the year's influenza season. Because this composition changes every year, last year's vaccine may not contain the right viral antigens for this year and the person would be unprotected.

What is the most important question to ask a 68-year-old adult who requests to receive the shingles vaccination? a. Is there any possibility you might be pregnant? b. Did you have chickenpox as a child or an adult? c. Do you have either type 1 diabetes or type 2 diabetes? d. Did you receive a seasonal influenza vaccination last year?

ANS: B The shingles vaccination is actually a booster injection to help a person who already has learned to make antibodies to the virus that causes chickenpox (varicella zoster) to make more of them to attack the residual virus in his or her body to prevent an outbreak of shingles. If a person has never had chickenpox, he or she is not at risk for shingles and the vaccination would be useless. Having diabetes or having received a seasonal influenza vaccination a year ago is not a contraindication for vaccination. A 68-year-old is out of the childbearing range.

With which disorder or organism is a killed vaccine used to trigger immunity? a. Tetanus b. Influenza c. Hepatitis B d. Human papilloma virus

ANS: B The vaccines for tetanus, hepatitis B, and human papilloma virus are all toxoids. Only the vaccine for influenza has been inactivated and is considered a "killed" vaccine.

Which are types of vaccines? (select all that apply) a. Activated vaccines b. Attenuated vaccines c. Immunological vaccines d. Toxoid vaccines e. Naturally formed vaccines f. Biosynthetic vaccines

ANS: B, D, F The four types of vaccines currently available are inactivated vaccines, attenuated vaccines, toxoids, and biosynthetic vaccines.

The activity of which specific immune system cell must be suppressed to reduce transplant rejection episodes? a. Neutrophils b. Macrophages c. T lymphocytes d. B lymphocytes

ANS: C A specific type of T lymphocyte is most responsible for the immune system's rejection of transplanted tissues and organs. It is the cell type whose activity must be suppressed to allow continued functioning of any transplanted organ.

How are vaccination and immunization related? a. They are actually the same thing. b. They are completely unrelated to each other. c. The outcome of successful vaccination is immunization. d. The outcome of successful immunization is vaccination.

ANS: C Although many people use these two terms interchangeably, they actually are different. Vaccination is the process of administering a vaccine to a person in the hope that the person will respond by making antibodies against the substance in the vaccine and thus develop immunity to it. Thus successful vaccination results in immunization against the substance in the vaccine. Not every vaccination results in full immunization.

For which patient should vaccination with an attenuated vaccine be avoided? a. 18-month-old child who has asthma b. 36-year-old woman who has taken insulin by injection for 25 years c. 48-year-old man who has severe immunosuppression as a result of a stem cell transplant 1 month ago d. 66-year-old woman who takes the anti-inflammatory drug meloxicam (Mobic) daily for severe arthritis

ANS: C An attenuated vaccine contains live viruses that have been modified and should not be able to reproduce. When given to a person whose immune system is profoundly suppressed, such as those who have recently received a stem cell transplant, it can cause the person to actually develop the disease.

Which drug is administered as an oral agent? a. Antithymocyte globulin (Atgam) b. Basiliximab (Simulect) c. Sirolimus (Rapamune) d. Daclizumab (Zenapax)

ANS: C Antithymocyte globulin, basiliximab, and daclizumab are antibodies that are all administered intravenously. Only sirolimus is an oral drug.

Which antirejection drug belongs to the antiproliferative class? a. Basiliximab (Simulect) b. Cyclosporine (Neoral) c. Mycophenylate (CellCept) d. Tacrolimus (Prograf)

ANS: C Basiliximab is a monoclonal antibody. Cyclosporine and tacrolimus are from the calcineurin inhibitor class of immunosuppressant agents.

What would be the expected response in an Rh-positive infant who was accidentally injected with RhoGAM? a. The infant would rapidly develop antibodies to Rh-positive red blood cells. b. The infant would rapidly develop antibodies to Rh-negative red blood cells. c. Some of the infant's Rh-positive red blood cells would be destroyed. d. The infant's blood type would change from Rh-positive to Rh-negative.

ANS: C RhoGAM is a collection of antiRh-positive antibodies. They would bind to some of the infant's Rh-positive red blood cells and destroy them. Because the infant has many more red blood cells than there are antibodies in RhoGAM, the accidental injection could not destroy all or even most the infant's red blood cells. The infant may develop a few antibodies against RhoGAM but will not make them against red blood cells that are either Rh-positive or Rh-negative. The infant's blood type for Rh will not be affected.

What specific direction should you teach a patient prescribed to take cyclosporine (Neoral) liquid suspension daily to prevent an acute rejection episode? a. Rotate injection sites at least weekly. b. Be sure to always take the capsule with grapefruit juice. c. Rinse the container with milk or juice and drink the rinse. d. Stop the drug immediately if you develop a high fever.

ANS: C The activity of the drug is dependent on taking the entire dose. The liquid suspension must be diluted and mixed correctly. Some of the drug sticks to the sides of the mixing container. Instruct the patient to rinse the mixing container and then drink the rinse to ensure he or she receives an effective dose.

What general precaution is most important to teach a patient taking any selective immunosuppressant agent? a. Report a lightening of urine color to your prescriber immediately. b. Eat a diet that is high in fruits and vegetables. c. Drink at least 4 L of liquids every day. d. Avoid crowds and people who are ill.

ANS: D All selective immunosuppressant agents reduce immune function to some degree and increase the risk for the person to develop an infection.

Why is an infusion of muromonab-CD3 (Orthoclone) more likely to result in an allergic reaction than an infusion of mycophenolate (CellCept)? a. Muromonab-CD3 is administered for shorter time periods than is mycophenolate. b. Muromonab-CD3 is administered in much higher dosages than is mycophenolate. c. Mycophenolate is an antiproliferative agent and muromonab-CD3 is a polyclonal antibody. d. Mycophenolate is a synthetically manufactured drug and muromonab-CD3 is produced using mouse proteins.

ANS: D Although partially humanized, muromonab-CD3 contains mouse proteins that are likely to stimulate an allergic reaction in humans. Most humans, by the time they are adults, have been exposed to mouse proteins and have antibodies to them that can trigger allergic reactions to anything that contains mouse proteins, especially when they are infused intravenously.

A mother of a 6-month-old infant who is to receive a vaccination against diphtheria, pertussis, and tetanus today asks why her baby needs this third injection when she has already received two previous vaccinations against these diseases. What is your best answer? a. The first two injections provided your baby with passive immunity and this one will provide active immunity. b. The first two injections provided protection against diphtheria and pertussis whereas this one is against tetanus. c. Infants have some protection against these disorders because you had these vaccinations as a child, but now that protection is gone. d. Infants have immature immune systems that are only capable of making a few antibodies at a time after vaccination and need frequent boosting.

ANS: D Because an infant's immune system is just beginning to develop, early vaccinations do not result in full immunization. They must receive repeated vaccinations in order to force the immune system to generate enough antibodies to provide sufficient artificially acquired immunity to protect against the development of diphtheria, pertussis, and tetanus. More booster vaccinations are required in childhood and adulthood.

Why can antibody-mediated immunity be transferred from one person to another person? a. White blood cells from one person are recognized as "foreign" by another person and trigger an immunologic response. b. When antibodies bind to antigens, the entire complex can then be totally eliminated from the body. c. Reexposure to the same microorganism results in greatly increased production of specific antibodies. d. Formed antibodies are released as free substances into the blood and other body fluids.

ANS: D Because antibodies are released from the cells that synthesized them and enter the blood, they can be collected from the blood of one person and injected into another person to provide temporary passive immunity to the receiving person.

Which vaccination is routinely administered to infants at ages 2 months, 4 months, and 6 months? a. HyperTET b. RhoGAM c. TdaP d. DTaP

ANS: D HyperTET is only given to a person who is heavily exposed to the tetanus organism and does not have adequate immunity to the organism. RhoGAM is only given to an Rh-negative woman who has given birth to an Rh-positive newborn. TdaP is a modified vaccination of tetanus, diphtheria, and pertussis given to older children and adults who have already received the DTaP series. DTaP is the vaccination given in infancy and early childhood to develop immunity to diphtheria, tetanus, and pertussis.

With which drug is it important to assess the patient's lipid levels? a. Azathioprine (Imuran) b. Basiliximab (Simulect) c. Tacrolimus (Prograf) d. Sirolimus (Rapamune)

ANS: D Sirolimus can cause elevation of both cholesterol and triglyceride levels. None of the other agents listed have this side effect.

Which exposure situation can lead to the development of "naturally acquired" immunity? a. Receiving seasonal influenza vaccination every year b. Taking a dose of oral polio vaccine c. Breastfeeding an infant d. Catching a cold

ANS: D Taking any type of vaccine allows development of artificial immunity rather than natural immunity. Breastfeeding an infant allows development of passive rather than active immunity. Catching a cold is a natural process that allows the person to develop naturally acquired active immunity.

What is the role of the T lymphocyte (T cell) in the development of long-lasting antibody-mediated immunity? a. Enhancing the sensitized B lymphocyte's production of antibodies on second and subsequent exposure to the same antigen b. Preventing general immune responses from becoming excessive and leading to autoimmunity c. Distinguishing sensitized B lymphocytes from unsensitized B lymphocytes d. Assisting unsensitized B lymphocyte to recognize new antigens

ANS: D The T lymphocyte has many roles in cell-mediated immunity. Its major role in antibody-mediated immunity is helping unsensitized B lymphocytes to recognize foreign invaders (antigens) and learn to make antibodies against them. T lymphocytes do not prevent autoimmunity and do not promote the memory function of increased antibody production on reexposure to the same antigen. T lymphocytes do not distinguish between sensitized and unsensitized B lymphocytes.

A woman whose father has shingles has a blood antibody titer to varicella zoster virus (VZV) of zero (0). What is the correct interpretation of this information? a. The woman has full immunity against shingles. b. The woman should receive the shingles vaccination. c. The woman is highly likely to develop shingles from her father. d. The woman is at risk for developing chickenpox from her father.

ANS: D The virus that causes chickenpox is varicella zoster (VZV). When people have already had chickenpox, they can have reactivation of the dormant virus whenever they are immunosuppressed, such as when they become older. Then the virus presents as shingles. A titer to VZV of zero indicates that the woman had never had chickenpox and has no immunity against VZV. Her father will be shedding active VZV while his shingles are present. If she is exposed to this virus, she could easily develop chickenpox.