Chapter 69: Immunosuppressants

9. A nursing student asks the nurse how antibodies provide immune suppression. The nurse responds by telling the student that antibodies: a. block T-cell function. b. boost immune responses. c. reduce proliferation of B cells. d. suppress interferon production.

A Antibodies can be directed against components of the immune system to suppress the immune response and block T-cell function. They inhibit rather than boost immune responses. They do not reduce the proliferation of B cells or suppress interferon production.

4. A patient with a history of lung transplantation is admitted for treatment for a respiratory infection. The patient has been taking cyclosporine [Sandimmune], prednisone, and azathioprine [Imuran] for 8 months. The provider has ordered azithromycin [Zithromax] to treat the infection and acetaminophen [Tylenol] as needed for fever. The nurse will contact the provider to: a. ask whether a different antibiotic can be used. b. ask that the prednisone be discontinued until the infection clears. c. suggest increasing the dose of cyclosporine. d. suggest using ibuprofen instead of acetaminophen.

A Macrolide antibiotics, such as azithromycin, can inhibit cyclosporine metabolism, leading to increased levels of the drug. This patient needs either a reduced dose of cyclosporine or a different antibiotic. There is no indication for discontinuing the prednisone during treatment. The dose of cyclosporine would need to be reduced, because azithromycin leads to increased drug levels. There is no contraindication to using acetaminophen.

1. A patient has undergone liver transplantation. The provider orders cyclosporine [Sandimmune], prednisone, and sirolimus [Rapamune]. What will the nurse do? a. Question the order for sirolimus. b. Request an order for a serum glucose level. c. Request an order for a macrolide antibiotic. d. Suggest changing the cyclosporine to tacrolimus.

A Sirolimus is given to prevent rejection in renal transplantation; it has no proof of efficacy in patients with heart, lung, or liver transplants. A serum glucose level is not indicated; patients taking repaglinide for diabetes should be monitored closely while taking cyclosporine. Although antibiotic prophylaxis may be necessary, macrolide antibiotics increase the level of cyclosporine. Tacrolimus is more toxic than cyclosporine.

14. A patient who is taking azathioprine [Imuran] to prevent rejection of a renal transplant develops gout and the provider orders allopurinol. The nurse will contact the provider to discuss: a. decreasing the allopurinol dose. b. decreasing the azathioprine dose. c. increasing the allopurinol dose. d. increasing the azathioprine dose.

B Allopurinol delays conversion of mercaptopurine to inactive products and increases the risk of azathioprine toxicity. Patients taking the two concurrently should have an approximate 70% reduction in the azathioprine dose. Altering the allopurinol dose is not indicated.

6. A patient is started on immunosuppressant drugs after kidney transplantation and will be taking azathioprine [Imuran] as part of the drug regimen. The patient asks the nurse why it is necessary to have a specimen for a complete blood count drawn at the beginning of therapy and then periodically thereafter. The nurse explains that azathioprine can alter blood cells and tells the patient to report: a. alopecia. b. easy bruising. c. fatigue. d. gastrointestinal (GI) upset.

B Azathioprine can cause bone marrow suppression, resulting in neutropenia and thrombocytopenia; therefore, a CBC must be evaluated at baseline and periodically thereafter. Patients who have low platelet counts bruise easily, so this symptom should be reported. Alopecia occurs with azathioprine but is not a life-threatening side effect. Fatigue is not a common adverse effect. GI side effects occur but are not life threatening.

8. The nurse knows that which immunosuppressants are among the most effective? a. Azathioprine [Imuran] and everolimus [Zortress] b. Cyclosporine [Sandimmune] and tacrolimus [Prograf] c. Methotrexate [Rheumatrex] and muromonab-CD3 [Orthoclone OKT3] d. Sirolimus [Rapamune] and methylprednisolone

B Cyclosporine and tacrolimus are the most effective immunosuppressants available.

13. The nurse is caring for a 15-year-old patient who has undergone a liver transplant. Which provider order will the nurse question? a. Cyclosporine [Sandimmune] and ketoconazole [Nizoral] b. Everolimus [Zortress] 1 mg twice daily c. Prednisone 60 mg daily d. Tacrolimus [Prograf] 50 mcg/kg twice daily the day after surgery

B Everolimus is not approved in patients younger than 18 years of age. Ketoconazole can decrease the metabolism of cyclosporine and is often given concurrently to allow lower dosing and lower cost. Prednisone and tacrolimus are commonly used, and these doses are correct.

5. A patient is taking cyclosporine [Sandimmune] and prednisone to prevent organ rejection after right renal transplantation. The patient is febrile and complains of right-sided flank pain. The nurse reviews the patient's chart and finds that the patient's BUN and serum creatinine are elevated. The cyclosporine trough is 150 ng/mL. What will the nurse do? a. Be concerned that the left kidney is failing. b. Expect the provider to order intravenous methylprednisolone. c. Request an order for a urine culture. d. Suspect nephrotoxicity secondary to an elevated cyclosporine level.

B The patient is showing signs of acute organ rejection, which include pain at the graft site, fever, and elevated BUN and creatinine; therefore, intravenous methylprednisolone is indicated. Because the patient is having pain on the right side, along with fever and elevated renal function test results, there is no reason to suspect that the left kidney is failing or that an infection is present. The cyclosporine level is within normal limits.

7. A nurse is teaching a patient who is about to undergo allograft transplantation of the liver. Which statement by the patient indicates understanding of the post-transplant medications? a. "Immunosuppressants help reduce the risk of postoperative infection." b. "I will need to have periodic laboratory work to assess for toxicity." c. "I will need to take immunosuppressants until all signs of organ rejection are gone." d. "These drugs will prevent organ rejection."

B To prevent toxicity from high drug levels or organ rejection from low levels, blood levels of immunosuppressants should be checked periodically. Immunosuppressants do not prevent infection; they increase the risk of infection. Patients must take immunosuppressants for life. Immunosuppressants do not prevent organ rejection; they help minimize the risk.

10. The nurse is preparing to administer basiliximab [Simulect] to a patient to prevent acute rejection. By which route will the nurse administer the drug? a. Oral b. Intramuscular c. Intravenous d. Transdermal

C Basiliximab is used to prevent acute rejection and is administered intravenously.

12. The nurse is administering medications to a patient who is receiving cyclosporine [Sandimmune]. Which medication, when administered concurrently with cyclosporine, would warrant a reduction in the dosage of cyclosporine? a. Phenytoin [Dilantin] b. Prednisone c. Ketoconazole [Nizoral] d. Trimethoprim/sulfamethoxazole [Bactrim]

C Concurrent use of ketoconazole would warrant a reduction in the dosage of cyclosporine. Ketoconazole often is given concurrently with cyclosporine so that the patient's dosage of cyclosporine, which is costly, can be reduced. Phenytoin would cause a decrease in cyclosporine levels. Prednisone often is given concurrently with cyclosporine to suppress the immune response. Trimethoprim/sulfamethoxazole reduces levels of cyclosporine in the body.

3. A nurse provides teaching to a patient who has undergone kidney transplantation and will begin taking cyclosporine [Sandimmune], a glucocorticoid, and sirolimus [Rapamune]. Which statement by the patient indicates understanding of the teaching? a. "I should take sirolimus at the same time as the cyclosporine." b. "I will need to have my blood sugar checked regularly." c. "I will need to take an antibiotic to prevent lung infections." d. "Taking this combination of drugs lowers my risk of kidney damage."

C Immunosuppressant drugs increase the risk of infections, especially the BK virus, which can cause renal damage, and other organisms that cause lung infections. Patients taking these drugs must take antibiotics for the first 12 months to help prevent infection. Sirolimus and cyclosporine should be taken 4 hours apart. Patients with diabetes may have trouble with glucose tolerance and require monitoring. Taking cyclosporine and sirolimus increases the risk of renal damage.

11. The nurse is caring for a patient after recent renal transplantation. The patient is taking sirolimus [Rapamune] to prevent transplant rejection. What other medications would the nurse expect the patient to be taking? a. Rifampin and ketoconazole b. Carbamazepine and phenobarbital c. Cyclosporine and glucocorticoids d. Amphotericin B and erythromycin

C Sirolimus should be used in conjunction with cyclosporine and glucocorticoids to reduce the risk of transplant rejection. Rifampin can reduce and ketoconazole can increase therapeutic levels of sirolimus and cyclosporine; therefore, they are not indicated for transplant patients. Carbamazepine and phenobarbital are not indicated, because they can reduce the therapeutic levels of sirolimus and cyclosporine. Amphotericin B and erythromycin are not indicated, because they can increase the therapeutic levels of sirolimus and cyclosporine.

2. A patient with a liver transplant has been receiving cyclosporine [Sandimmune] for 6 months. The nurse reviews this patient's laboratory results and notes a sharp increase in the blood urea nitrogen (BUN) and serum creatinine. Vital signs are normal, and the patient reports no discomfort. What does the nurse suspect? a. Hepatotoxicity b. Infection c. Organ rejection d. Nephrotoxicity

D An elevation of BUN and serum creatinine is an indication of nephrotoxicity, which occurs in 75% of patients taking cyclosporine. Hepatotoxicity would cause elevations in liver enzymes, not the BUN and creatinine. Infection would be associated with fever. Organ rejection of a renal transplant would cause elevation in the BUN and creatinine but also would cause tenderness at the graft site and fever.