Module 2D - DMARCs, Chemo

Pharmacology

methotrexate (low dose) indication

• slows progression of rheumatoid arthritis and reduces joint damage in low doses usually once per week

• can take 3-6 weeks up to several months to become therapeutic

• not a cure

DMARDs

disease-modifying anti-rheumatic drugs

methotrexate low dose contraindications

• pregnancy category X

• liver disease or alcohol use disorder

methotrexate low dose adverse effects

• bone marrow suppression

• hepatotoxicity

• peptic ulcer/GI bleeds

• fetal death

methotrexate low dose labs

WBC, RBC, PLT, H&H, AST, ALT

methotrexate low dose assessment

• s/s of anemia, bleeding, infection

• s/s of decrease liver function

• s/s of peptic ulcers/GI bleed

methotrexate low dose teaching

• MOA - suppressed immune system to decrease inflammation and slow progression of RA

• s/s of excess bleeding: bleeding while brushing, bruising, nose bleeds

• s/s of infection: fever, body aches, chills, sore throat, cough

• s/s of anemia: fatigue, SOB

• NO LIVE VACCINES

• use contraceptives

• take with 8oz of milk or water or food

• s/s of decreased liver function: N/V, anorexia, abd pain

• s/s of GI bleed: black/tarry stools, coffee ground emesis

• take folic acid to reduce toxicity

methotrexate high dose indication

used to stop synthesis of rapidly growing cells (cancer cells and healthy cells)

methotrexate high dose contraindications

• pregnancy

• liver disease or alcohol use disorder

• kidney disease

methotrexate high dose adverse effects

• bone marrow suppression

• hepatotoxicity

• nephrotoxicity

• peptic ulcer/GI bleed

• mucositis

• fetal death

methotrexate high dose labs

WBC, RBC, PLT, ANC, H&H, AST, ALT, BUN, Creatinine

methotrexate high dose assessment

• s/s of bone marrow suppression

• s/s of neutropenia

• s/s of bleeding/peptic ulcers

• s/s of mucositis

• s/s of hepatotoxicity/nephrotoxicity

methotrexate high dose nursing intervention

• pre medicate with antiemetic 30min to 1 hr before

• discuss hair loss

• implement neutropenic precaution

• implement bleeding precautions

methotrexate high dose education

• take with 8oz of milk or water

• use contreaceptives

• notify provider if you notice s/s of bleeding, decreased liver or kidney function, infection, GI bleeds

tamoxifen indication

blocks estrogen receptors in treatment or prevention of hormone dependent or hormone receptor positive breast cancer

tamoxifen contraindications

• pregnancy

• history of thromboembolic events

• use of warfarin

• history of endometrial cancer

tamoxifen adverse effects

• thromboembolic events - DVT, PE

• endometrial cancer

tamoxifen side effects

hypercalcemia, bone pain, N/V, menopausal symptoms (hot flashes)

tamoxifen labs

BMP (specifically calcium), CBC,

tamoxifen assessment

• bone pain'

• s/s of PE - sudden SOB, chest pain, tachypnea, tachycardia

• s/s of DVT - unilateral leg swelling, pain, and warmth/discoloration

• s/s of stroke - slurred speech, facial droop or asymmetry, decrease LOC

tamoxifen pt teaching

• report s/s of DVT, PE, or stroke immediately

• have annual OBGYN visits w/ pap smears

• report vaginal bleeding

• perform weight bearing exercises to reduce bone loss

• avoid pregnancy

vaccines MOA

introducing antigen to the body → immune system respond by creating antibodies to fight the microbes and stop infection.

• immune system trained to identify and fight antigens

inactive vaccines

• killed or synthetically created parts of virus

• ex: Hep A, flu (IM), polio, rabies

live vaccines (LAIV)

• weakend but live

• ex: MMR, varicella, flu (nasal)

avoid LAIV in…

• younger than 2 y/o

• older than 49 y/o

• immunocompromised from HIV, chemo, steroid therapy

• pregnancy