Chapter 69: Immunosuppressants

A nurse monitors a patient who takes azathioprine [Imuran] for which adverse effects? (Select all that apply.) A. Leukopenia B. Thrombocytopenia C. Alopecia D. Nephrotoxicity E. Red urine color

A, B, and C Rationale: Azathioprine is a cytotoxic medication used to suppress the immune response. It is toxic to all proliferating cells. Cytotoxic medications usually are reserved for patients who have not responded to safer immunosuppressants. Nephrotoxicity and red-colored urine are not adverse reactions associated with azathioprine.

When assessing a patient for adverse effects of cyclosporine [Sandimmune], it is most important for the nurse to review which laboratory findings? (Select all that apply.) A. Creatinine level B. Hemoglobin level C. Platelet count D. Bilirubin level E. White blood cell (WBC) count

A, D, and E Rationale: Cyclosporine is an immunosuppressant medication used to prevent organ rejection. Adverse effects include significant neurotoxicity, renal toxicity, hepatotoxicity, and infection risk. The hemoglobin level and the platelet count are not adversely affected by cyclosporine.

The nurse is preparing to administer a medication for acute organ rejection. Which medication will the nurse prepare to administer? A. Methylprednisolone sodium [Solu-Medrol] B. Diphenhydramine [Benadryl] C. Acetaminophen [Tylenol] D. Meperidine [Demerol]

A. Rationale: Methylprednisolone sodium, a glucocorticoid, is administered intravenously to treat episodes of acute organ rejection. Diphenhydramine or acetaminophen would not be as effective as a steroid to minimize an adverse immune system reaction. Meperidine is a pain medication.

A pt is prescribed sirolimnus (Rapamune) and cyclosporine (Sandimmune) after renal transplantation. It is most important for the nurse to closely monitor which value? A. serum creatinine B. AST C. serum potassium D. partial prothromblastin time

A. Rationale: Sirolimus combined with cyclosporine poses a significant risk of renal injury. Renal function should be monitored.

Which medication does the nurse identify as a monoclonal antibody used to inhibit allograft rejection in transplant recipients? A. Mycophenolate mofetil [CellCept] B. Basiliximab [Simulect] C. Tacrolimus [Prograf] D. Sirolimus [Rapamune]

B. Rationale: Basiliximab is a monoclonal antibody that blocks the activation of T cells. It is used in the prophylaxis of organ rejection in the first 6 months after renal transplantation. Mycophenolate mofetil suppresses B- and T-lymphocyte proliferation. Tacrolimus and sirolimus suppress T lymphocytes.

After receiving an allograft liver transplant, a pt is prescribed cyclosporine (Sandimmune) oral solution. What is the most critical component of pt teaching that the nurse should address? A. the med will help prevent transplant rejection B. the oral solution can be mixed with orange juice C. the med will be taken every day for life D. the med causes reversible increase of hair growth

C. Rationale: Allograft recipients must take immunosuppressants for life to prevent transplant rejection. The other concepts are important to teach but are not as high of a priority.

A patient currently taking sirolimus [Rapamune] tells the nurse that she is starting a very low-fat diet. Which statement by the nurse is the most appropriate? A. "Low-fat diets don't work. You should try a low-carb diet." B. "It is fine to be on a low-fat diet with your medication, as long as you take it with food." C. "If you change the fat content in your regular diet you should check with your prescriber." D. "Diet will not affect your medication, so you can do whatever diet you would like."

C. Rationale: High-fat foods can increase sirolimus absorption by about 35%. To minimize variability, patients should take all doses consistently (ie, all with food having similar percentage of fat or all without food). The patient should maintain a consistent diet or speak with the prescriber about possible changes in medication doses.

A transplant recipient is receiving cyclosporine [Sandimmune]. Which response should a nurse expect if the medication is having the desired effect? A. Increased antibody response B. Increased natural killer (NK) cellular activity C. Suppression of T lymphocytes D. Suppression of hepatic metabolism of steroids

C. Rationale: Immunosuppressants inhibit T-lymphocyte synthesis through inhibition of calcineurin, thus reducing the immune response to organ transplants. Increased antibody response, increased NK cellular activity, and suppression of hepatic metabolism of steroids are not actions of cyclosporine.

Which instruction should be the priority for the nurse to teach a patient scheduled to start taking sirolimus [Rapamune]? A. "A lipid-lowering medication can be given to lower cholesterol levels." B. "There might be some joint pain, diarrhea, and rash with this medicine." C. "You'll need to notify your doctor if you experience any sore throat or fever." D. "Take this medication with food, but you'll need to avoid taking it with grapefruit juice."

C. Rationale: Sirolimus is an immunosuppressant approved only for preventing renal transplant rejection. It raises the risk of infection, and patients need to take precautions to avoid sources of contagion. Side effects include rash, joint pain, diarrhea, and increased levels of cholesterol, and taking sirolimus with grapefruit juice inhibits the drug's metabolism; these are lower levels of priority than the infection risk.

When caring for an 21-year-old female pt, post kidney transplantation, who is taking cyclosporine (Sandimmune) and repaglinide (Prandin), what should the nurse do? A. administer the medication with grapefruit juice B. monitor the pt for hyperglycemia C. encourage the pt to take an oral contraceptive D. assess the pt for signs and symptoms of infection

D. Rationale: Cyclosporine increases the risk of infection and can result in kidney damage primarily in kidney recipients. Grapefruit juice should be avoided because it alters the metabolism of the drug. Cyclosporine also can increase the levels of repaglinide and can cause hypoglycemia. Pts taking cyclosporines should be advised to use a mechanical form of contraception rather than oral forms.

methotrexate (Rheumatrex) uses

RA, psoriasis, suppression of B and T lymphocytes that interfere with folate metabolism (pt must take a folic acid supplement)

Therapeutic uses of azathioprine (Imuran)

adjuvant treatment with transplants and autoimmune disorders

Mitoxantrone (Novantrone)

anticancer agent; reduces neurologic disability and relapse for MS pts; reserved for pts not responsive to safer drugs

cyclophosphamide

anticancer drug

basiliximab

blocks activation of T cells and is used in prophylaxis of acute organ rejection after renal transplantation

Adverse effects of azathioprine (Imuran)

blood dycrasias (low blood cell counts), nausea, vomiting, mutagenic and teratogenic, neoplasms, and pancreatitis

Adverse effects of cytotoxic drugs

bone marrow suppression (neutropenia and thrombocytopenia), GI disturbances, reduced fertility, and alopecia

What are the most effective anti-rejection immunosuppressants available?

cyclosporine, tacrolimus, and primecrolimus

Therapeutic effects of lymphocyte Immune Globulin (Atgam), antithymocyte (equine)- antibodies

decrease in the number and activity of thymus-derived lymphocytes

Adverse effects of basiliximab

doesn't increase risk of opportunistic infections and no cancers have been reported after 1 year of treatment (generally well tolerated)

cyclosporine (Sandimmune) drug and food interactions

drugs that increase and decrease cyclosporine levels, nephro or hepatotoxic drugs, grapefruit juice, and repaglinide

Lymphocyte Immune Globulin (Atgam), antithymocyte (equine) (antibodies)

extracted from horses who have been inoculated with human T lymphocytes

Therapeutic uses of cyclosporine (Sandimmune)

for organ rejection (kidney, liver, and heart) and used for some autoimmune diseases

Adverse effects of lymphocyte Immune Globulin (Atgam), antithymocyte (equine)- antibodies

hypersensitivity and anaphylaxis

Adverse effects of large doses of glucocorticoids

increased risk for infection, thinning of the skin and bones, bone dislocation with fracture, impaired growth in children, and adrenal suppression

Toxicity of immunosuppressants

increased risk of infection and increased risk of neoplasms (tumor growth-even at therapeutic doses)

Immunosuppressants

inhibit the immune response

Adverse effects of cyclosporine (Sandimmune)

nephrotoxicity, hepatotoxicity, infection, lymphoma, hypertension, tremor, hirsutism, leukopenia, gynecomastia, sinusitis, hyperkalemia, and anaphylactic reactions

Uses of immunosuppressants

prevention of organ rejection and treatment of autoimmune diseases

Calcineurin use

prevention of organ rejection in transplant recipients

Uses of lymphocyte Immune Globulin (Atgam), antithymocyte (equine)-antibodies

prevents rejection of renal transplants and treats aplastic anemia

Cytotoxic drugs

suppress the immune response by killing B and T lymphocytes undergoing proliferation

azathioprine (Imuran)

suppresses cell-mediated and humoral immune responses

Cyclosporine (Sandimmune) MOA

suppresses the production of interferon gamma and other cytokines

Uses of glucocorticoids

suppression of rejection, treatment of asthma, RA, systemic lupus, and multiple sclerosis

Why can cytotoxic drugs be harmful?

they are killing all proliferating cells; we want them to kill cancer cells but other cells that are dividing like skin, hair, and mucous membranes- we want these cells to be able to proliferate

Nonspecific cytotoxic drugs

toxic to all proliferating cells