Immunomodulators: Stimulants and Suppressants

Immunomodulators: Comprehensive Study Notes

Introduction to Immunomodulators

• Definition: Immunomodulators are drugs that work at different parts of the immune system to either stimulate or inhibit the immune response.

• Key Terms:

  • Immune Stimulants: Drugs used to boost the body's natural immune system, typically when fighting a long-term infection.

  • Immune Suppressants: Drugs used to stunt or inhibit the immune system, primarily for organ transplant rejection, autoimmune diseases, and some cancers.

  • Monoclonal Antibodies (mAbs): Specific antibodies created by one strain of B cells to target specific antigens.

  • Recombinant DNA Technology: A process that uses bacteria to produce chemicals that naturally occur in the body.

General Considerations for Immunomodulator Therapy

• Infection Risk: Patients on immunomodulators, especially suppressants, must be extra careful to avoid infections as their immune system may not eliminate them normally. Family members should also be aware.

• Teratogenicity: Immunomodulators were found to be teratogenic in animals. Therefore, they are contraindicated for individuals who could become pregnant or are breastfeeding.

• Fertility Effects: These drugs can affect fertility in both men and women. Sperm motility may decrease, and an over-efficient immune system could kill sperm before fertilization.

• Administration Techniques (Injections):

  • When a patient administers an injectable dose, a healthcare professional should watch them after teaching proper technique to ensure correct administration and infection prevention.

  • Family members should also know how to administer the drug in case the patient cannot self-administer.

• Age-Specific Dosing:

  • Children: Require higher doses due to their body's surface area to weight ratio and faster metabolism.

  • Older Adults: Have slower metabolism and are more susceptible to adverse effects.

• Overall Patient Burden: Receiving immunomodulators is a heavy burden due to increased infection risk, potential renal/hepatic damage, frequent sickness, and the underlying major diagnosis requiring treatment. Mental health considerations are crucial for patient care.

Immune Stimulants

• Purpose: Used to boost the immune system, particularly after prolonged infection.

• Three Main Types:

$1$. Interferons

• Actions:

  • Prevent the spread of viruses within the body by entering non-infected cells and making antiviral proteins to prevent infection.

  • Stimulate other immune components like T cells and phagocytes.

  • Fight tumors and communicate with lymphocytes.

• Specific Medication: Interferon alpha-${2}b$

• Therapeutic Uses: Protect cells, slow tumor progression, effective against certain cancers:

  • Leukemias

  • Kaposi sarcoma

  • Malignant melanoma

  • Follicular lymphoma

• Adverse Effects:

  • Cardiac problems: Arrhythmia, hypertension (use caution in patients with pre-existing cardiac issues).

  • Myelosuppression: Can exacerbate existing myelosuppression and further decrease bone marrow activity.

  • Central Nervous System (CNS) Effects: Changes in behavior, CNS depression.

$2$. Interleukins

• Actions: Chemicals produced by T cells for communication between leukocytes. Boost immunity by:

  • Increasing the activity of natural killer cells.

  • Increasing cytokine production.

  • Increasing the number of platelets.

• Specific Medications:

  • Aldesleukin: A human interleukin produced by recombinant DNA technology using E. Coli bacteria.

  • Oprelvekin: A thrombocytopenia growth factor that stimulates stem cells to mature into platelets.

• Contraindications:

  • Pregnancy or lactation.

  • Renal or hepatic problems (metabolized and excreted by liver and kidneys).

• Adverse Effects:

  • Cardiovascular effects (similar to interferons).

  • CNS effects.

  • Flu-like symptoms.

  • Oprelvekin-specific: High potential for hypersensitivity reactions. Patients must be monitored closely upon initiation and instructed to report chest tightness, trouble breathing, or trouble swallowing immediately.

$3$. Colony Stimulating Factors (CSFs)

• Actions: Created using recombinant DNA technology. Used to:

  • Reduce neutropenia after bone marrow transplantation and chemotherapy.

  • Assist in treating cancers of the blood.

• Specific Medications: Filgrastim and Pegfilgrastim

• Contraindications:

  • Bone marrow cancer or sickle cell disease (will stimulate reproduction of defective cells, worsening the condition).

  • Sensitivity to E. Coli products (due to recombinant DNA manufacturing).

  • Concurrent radiation and chemotherapy (can decrease drug effectiveness; typically given after chemotherapy is completed).

  • Neonates, pregnancy, or breastfeeding (effects are not known).

• Adverse Effects (due to bone marrow stimulation and immune activity):

  • Gastrointestinal: Nausea, vomiting, constipation, diarrhea.

  • Dermatological: Alopecia, dermatitis (overactive cytokines attacking hair follicles and skin).

  • Hematological: Splenomegaly (enlarged spleen), leukocytosis (increased white blood cell count; WBC count needs to be monitored).

Nursing Considerations for Immune Stimulants (and General Immunomodulators)

• Assessment:

  • Gather baseline information: Pregnancy status, kidney, liver, or cardiac problems.

  • Perform baseline assessments: EKG, skin assessment, labs (e.g., CBC, renal/hepatic function), CNS assessment. This helps determine if patients are declining or responding well.

• Patient Education:

  • Thoroughly inform patients about expected adverse effects and how to mitigate them to improve compliance.

  • Advise use of acetaminophen and adequate hydration to prevent a large portion of adverse effects, especially flu-like symptoms.

  • Provide detailed education on proper administration technique, especially for injections, to reduce infection risk.

  • Discuss the increased risk of infection, renal/hepatic damage, and frequent sickness, which can potentially last for life depending on the condition.

  • Emphasize careful mental health support due to the burden of treatment and underlying diagnoses.

• Implementation:

  • Check lab work regularly throughout treatment to avoid severe adverse effects.

  • Monitor closely for acute signs of hypersensitivity when patients first start these drugs.

  • Strongly encourage patients to use barrier methods for contraception, not just hormonal birth control, due to teratogenicity and fertility impact.

  • Ensure strict adherence to correct aseptic technique for all invasive procedures in these immunocompromised patients.

• Evaluation:

  • Assess if the drug is effectively helping the patient's condition.

  • Verify patient compliance: Are they taking the drug as directed? If not, investigate reasons (e.g., severe adverse effects).

  • Evaluate adverse effect severity: Are they manageable with minor adjustments (e.g., acetaminophen and hydration) or do they require further intervention?

Immune Suppressants

• Purpose: Used to inhibit the immune system for organ transplant, autoimmune diseases, and some cancers.

• Four Main Types:

$1$. Immune Modulators (Specific Class)

• Actions: Block the release of various cytokines involved in inflammatory responses and the activation of lymphocytes, thereby decreasing immune activity.

• Specific Medication: Apremilast

• Therapeutic Uses: Treats psoriatic arthritis (an inflammatory disease) by reducing joint pain and swelling and improving scalp and nail psoriasis.

• Adverse Effects/Interactions: As a newer drug class, confirmed adverse effects or drug-to-drug interactions are not yet established.

$2$. T and B Cell Suppressors

• Actions: Prevent specific transplant rejections.

• Specific Medications: Cyclosporine, Mycophenolate, and Tacrolimus

• Cyclosporine-Specific Effects:

  • Used when patients have had multiple rejection reactions with other T and B cell suppressors being ineffective.

  • Can cause hirsutism and overgrowth of the gums.

• Contraindications:

  • Known hypersensitivity.

  • Pregnancy or lactation.

  • Renal or hepatic problems (can affect drug excretion).

• Adverse Effects (serious):

  • Increased infection risk.

  • Increased neoplasms (due to decreased immune system ability to fight tumors).

  • Renal and hepatic toxicity: Requires routine lab monitoring of kidney and liver function. Avoid concurrent administration with other nephrotoxic or hepatotoxic drugs.

$3$. Interleukin Receptor Antagonists

• Actions: Blocks interleukin receptors from being stimulated, thereby reducing their immune-boosting effects (antagonist means "less of").

• Specific Medication: Anakinra

• Therapeutic Uses: Treatment of rheumatoid arthritis when other traditional treatments have not been effective.

• Contraindications:

  • Known reactions to E. Coli products (medication made using recombinant DNA technology and E. Coli).

  • Pregnancy or lactation.

  • Active infection.

  • Renal issues.

• Adverse Effects:

  • Mild pain at the injection site after administration.

  • Common immunomodulator adverse effects: Flu-like symptoms, GI upset.

• Drug-Drug Interactions: Do not combine Anakinra with Etanercept, as this only increases the risk of sepsis without improving disease treatment.

$4$. Monoclonal Antibodies (mAbs)

• Naming Convention: Drugs often include "mab" in their names (e.g., MAb: monoclonal anti-body).

• Actions: Designed to attach to particular cells, viruses, bacteria, or other antibodies. Many types exist. Those listed here specifically deactivate roaming tumor necrosis factor (TNF), thereby decreasing inflammation.

• Therapeutic Uses (wide variety): Cancers, arthritis, Crohn's disease, ulcerative colitis, multiple sclerosis.

• Contraindications:

  • Pregnancy or lactation.

  • Fluid overload (can be exacerbated by these drugs).

  • Fever: Treat fevers before administration. It is crucial to determine the cause of the fever: if infection-related, the drug is likely contraindicated; if related to the disease process being treated, it may be given. Requires thorough patient communication and health history assessment.

• Adverse Effects:

  • Most common: Flu-like symptoms.

  • Most concerning reaction: Acute pulmonary edema, potentially caused by cytokine release syndrome, which can lead to shock if followed by fluid retention.

  • Increased risk of serious infection that could lead to sepsis if combined with other immune suppressants.

Nursing Considerations for Immune Suppressants

• Monitoring:

  • Routine lab work: Specifically monitor renal and liver function, and white blood cell count.

  • Cardiac changes.

  • Acute reactions: Watch for symptoms beyond flu-like, such as a cough after infusion begins (sign of throat edema, requiring quick intervention).

• Assessment Before Administration: Inquire about any active infections or if the patient is taking antibiotics.

• Implementation:

  • Ensure regular lab work is completed.

  • Provide thorough patient education on proper injection technique to the patient and any assisting family members; observe self-administration to verify understanding.

  • Follow correct aseptic technique for all invasive procedures in these immunocompromised patients.

  • Educate patients on the increased risk of infection and how to mitigate it.

  • Make patients aware of common adverse effects and how to acquire adequate support during treatment.

  • Emphasize the importance of using barrier methods (condoms), not just hormonal birth control.

  • More informed patients are more likely to be compliant with treatment, safer, and this also protects the healthcare provider's license.

• Evaluation:

  • Assess the effectiveness of patient teaching and review material if necessary.

  • Keep track of the severity of adverse effects.

  • Review lab work to ensure the treatment is not compromising other body systems.