Immunostimulants and Immunomodulators (Chap 48)
Epoetin alfa
-Epogen, Procrit, Retacrit -anemias associated w CKD -ads rxn: HTN, headache, n/v, fatigue Titrated to Hb level (should be no higher than 12 g/dL) -contraindicated in patients w HTN, hypersensitivty to human albumin
Filgrastim
-Neupogen -colony stimulating factor -treat/prevent severe neutropenia (caution with hypothyroid) -start 24 hours after chemo -ads rxns: bone pain, n/v, diarrhea, alopecia 5-10 mcg/kg subQ or IV daily
Vitamin B12
-cyancobalamin -ads rxn: mild diarrhea, itching, edema -need intrinsic factor to absorb -B12 deficiency causes macrocytic anemia -Alchol, neomycin, colchicize, decrease absorption of oral B12
Folic Acid
-megaloblastic anemia from deficiency of folic acid -ads rxn: allergic sensitzation 1 mg/day, PO, IM, IV, sub Q -in leafy greens, meat, poultry, whole grains -take w pregnancy to decrease neural tube defects (0.8 mg/day) -if taken w hyantoins can cause seizure
Ferrous
-prevent/treat iron anemia ads rxn: GI irritation, n/v, constipation, diarrhea
What is the recommended daily amount of folic acid during pregnancy and lactation?
0.8 mg/day
What lab value is important with CSFs?
Absolute neutrophil count (ANC)
What are treatment guidelines for filgrastim?
Absolute neutrophil count (ANC) is monitored and therapy is continued until an ANC of at least 10,000 mm3 is achieved
What should clients avoid while taking interferons and why?
Alcohol because it causes an asymptomatic elevation in liver enzyme
When is CSF filgrastim (Neuopgen) started?
CSF filgrastim is started at least 24 hours after the completion of a cycle of chemotherapy
How are CSFs used in hematopoiesis?
CSF used to signal undifferentiated stem cells in bone marrow to multiple and differentiate into erythrocytes, leukocytes, or megakaryocytes
How do CSFs affect thrombopoiesis?
CSFs increase/stimulates thrombopoiesis
Promacta
Eltrombopag
Epogen, Procrit, Retacrit
Epoetin alfa
What causes fatigue associated with CSF use?
Fluid retention
What are common GI reactions to iron?
GI irritation, n/v, constipation, diarrhea, darker stools
What two patient conditions are contraindications of iron use?
Hemochromatosis or hemolytic anemia
Which administration route can cause a brownish discoloration of the skin?
IM route
What lab value is important for CSFs?
ITP and platelet count
What can thrombocytopenia cause
Idiopathic thrombocytopenic purpura (ITP)
Does adequate folic acid decrease the risk for embryonic neural tube defects?
If taken before conception and during early pregnancy
What can chemo drugs cause from impact on neutrophils?
Infection can result if client develops neutropenia
What are two classifications of cytokines?
Interferons and Colony-Stimulating Factors (CSFs)
Is there an increase or decrease in absorption of iron when taken with vitamin C?
Iron absorption is increased when taken with vitamin C
Should iron be taken with food or other medications?
Iron should be taken on an empty stomach
If anemia is associated with diet, what strategies can the nurse use to encourage adequate dietary intake?
Lean red meats, cereals, dried beans, and leafy green vegetables, liver, yeast, beef, pork, eggs, milk, and milk products
What happens to the levels of antibiotics or levothyroxine when taken with iron?
Levels of antibiotics and levothyroxine are decreased in absorption when taken with iron
What is one of the major conditions that interferons treat?
Multiple Sclerosis (MS)
In clients on ESAs such as epoetin alfa, what should their hemoglobin level be no higher than?
No highter than 12 g/dL, if higher?
What medication is used to treat iron deficiency anemia?
Oral iron supplements are used to treat iron deficiency anemia
Eltrombopag
Promacta -severe chronic thrombocytopenia (ITP) -ads rxn: excessive menstural bleeding, nausea -max dose 75 mg/day -can be toxic to liver, discontinuation can lower platelet counts
What are the 3 distinct cells that circulate in the blood?
RBC (erythrocytes) WBC (leukocytes) Platelets (megakaryocytes)
What is a patient is hypersensitive to aspirin- should the nurse take special precautions?
Take precaution because of hypersensitivity to tartrazine or sulfite
Why are neutrophils a prime target for destruction by chemotherapy drugs and cancer cells?
They have a rapid growth cycle
What do ESAs treat?
Used to treat anemia in CKD, chemotherapy for cancer treatment, AZT therapy for HIV, and postsurgical blood replacement in place of allogenic transfusions
What are cytokines?
a broad group of proteins involved in cell-to-cell communication
What can cause a B12 deficiency?
a deficiency of intrinsic factor results in abnormal formation of erythryoctyes becasue of body failure to absorb vitamin B12
What are colony-stimulating factors (CSF)?
a group of immunostimulants used in cancer treatment and chronic renal failure to support hemopoietic system
How should adverse reactions of interferons be treated?
acetaminophen and antihistamines
What substances may decrease the absorption of oral vitamin B12?
alcohol, neomycin, and colchicine
What are the categories of interferons?
alfa, beta, gamma
A patient with interferons is more likely to have?
an infection (reduction in WBC)
What should never be given concurrently with iron?
antacids or milk
What is iron deficiency anemia?
body doesn't have enough iron, iron is in hemoglobin and picks up oxygen from lungs and carries it to the body tissues
What are the general system reactions of CSFs?
bone pain, HTN, n/v, alopecia, hypersensitivity or allergic reactions
How do interferons treat Multiple Sclerosis (MS)?
by interferon beta-1b to enhance T cell activity and reduce inflammation in CNS
When taking oral iron, how can a patient prevent teeth staining?
by mixing liquid iron preparation with water or juice and drink through a straw
What are uses for CSFs?
cancer, kill off fast growing cells of hematopoietic system
What medication is used to treat a vitamin B12 deficiency?
cyanocobalamin
How do interferons work?
cytokine antiviral agents that get their name from ability to interefere with viral replication inside the cell -stimulate phagocytoes to be more aggressive, stimulate receptors on other healthy cells to prevent viral invasion, prevent viruses from replicating inside of host cells, inhibit tumors/stimulate T cells, act as anti-viral to some bacterial infections
What are immunomodulators
drugs that modify the actions of the immune system
What are erythropoiesis-stimulating agents (ESAs)?
drugs that stimulate erythropoiesis, making RBCs.
When would supplemental iron be needed?
during pregnancy and lactation
What signs should the nurse look for for parenternal administration of iron dextran (fatal anaphylactic-type reactions)?
dyspnea, urticaria, rashes, itching, and fever
In anemia caused by chronic kidney disease, what substance in the body is reduced, resulting in decreased RBC production?
erythropoietin?
Neupogen
filgrastim (CSF)
What are common adverse reactions of interferons?
flu-like symptoms: chills, cough, fever, headache, malaise
When should you give interferons to help avoid adverse reactions?
give in evening
Filgrastim should be used with caution in clients with what condition?
hypothyroid disease
What can happen if a client develops neutropenia?
infection
What is anemia?
insufficient amount of hemoglobin delivering oxygen to tissues
what are man made cytokines?
interferons and interleukins
What substane is required to absorb B12?
intrinsic factor (made by cells in stomach)
In patients being treated for HTN, what is vitally important if they are taking epoetin alfa?
it is important if they are taking epoetin alfa because it can result in increased mortality, or serious cardio/thromboembolic events
What foods contain folic acid?
leafy greens, fish, meat, poultry, whole grains
What organ is susceptible to damage from Eltrombopag?
liver, should do liver studies
What can happen if Eltrombopag is discontinued?
lower platelet counts
What anemia does B12 cause?
macrocytic anemia
What type of anemia does folic acid deficiency cause?
megaloblastic anemia
Should interferons be taken during pregnancy?
no, unless the woman is at high risk of MS activity
What are the different preparations of iron?
parenteral, oral iron preparations
What are the cardiovascular system reactions that can occur with CSFs?
peripheral edema, palpitations, atrial fib, emboli resulting in stroke and pulmonary edema, capillary leak syndrome
What is megaloblastic anemia?
presence of large, abnormal, immature erythrocytes circulating in the blood
What is thrombopoiesis?
production of platelets
Cytokines
proteins that are messengers to communicate between cells
How does Interferon B (REBIF) work?
reduces ability to APC to activate T cells (prevents cascade)
What can happen if folic acid is administered with hydantoins?
seizure activity
Because CSFs can cause hypersensitivity reactions, what can you expect to be ordered to maintain their use?
should be ordered with antihistamines, steroids, and bronchodilators
What are interleukins?
specific cytokines made by WBC and boost immune system during cancer therapy
What is a thrombopoietin receptor agonist?
stimulate megakaryocytic production
What is hematopoiesis?
stimulate the body to make more of the specific blood cells
Aldesleukin/Proleukin
synthetic form of interleukin-2, activates cancer attacking cells, causing them to reproduce so they can target cancer cells *always given in hospital setting, risk of severe hypotension
How can a nurse encourage the patient to continue taking CSF?
teach energy saving skills
What strategies can the nurse use to help prevent or treat constipation in a patient taking iron?
to prevent constipation= increase fluid intakes, eat diet high in fiber, active lifestyle
Epoetin alfa contraindicated in patients with what conditions?
uncontrolled HTN, in need of emergency transfusion, and hypersensitvity to human albumin